Provider Demographics
NPI:1396130555
Name:KENNEDY, ALICE (MD)
Entity type:Individual
Prefix:DR
First Name:ALICE
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ALICE
Other - Middle Name:WAN
Other - Last Name:BEHRENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9800 BAPTIST HEALTH DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6229
Mailing Address - Country:US
Mailing Address - Phone:501-223-8400
Mailing Address - Fax:501-223-3713
Practice Address - Street 1:924 MAIN ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-5424
Practice Address - Country:US
Practice Address - Phone:501-327-4444
Practice Address - Fax:501-327-3962
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-03
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-13990207WX0107X
390200000X
TXS0629207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR273545001Medicaid
ARE-13990OtherARKANSAS MEDICAL LICENSE
TXFB8202791OtherDEA