Provider Demographics
NPI:1457910861
Name:KENNEDY, BAILEY R (OD)
Entity Type:Individual
Prefix:
First Name:BAILEY
Middle Name:R
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 1:142 TOP FLIGHT DR
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76087-4007
Mailing Address - Country:US
Mailing Address - Phone:817-771-0241
Mailing Address - Fax:
Practice Address - Street 1:126 S RANCH HOUSE RD STE 1000
Practice Address - Street 2:
Practice Address - City:WILLOW PARK
Practice Address - State:TX
Practice Address - Zip Code:76008-2783
Practice Address - Country:US
Practice Address - Phone:817-441-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9669T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist