Provider Demographics
NPI:1245892397
Name:KENNEDY, DEVON (OD)
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 420
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-0420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44815 FIG AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3144
Practice Address - Country:US
Practice Address - Phone:661-206-9753
Practice Address - Fax:844-897-3788
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34233TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist