Provider Demographics
NPI:1780902486
Name:KENNEDY, NICOLE LYNETTE (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNETTE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 PROFESSIONAL PARK DRIVE
Mailing Address - Street 2:SIMCA
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959
Mailing Address - Country:US
Mailing Address - Phone:618-997-2161
Mailing Address - Fax:618-997-2464
Practice Address - Street 1:3411 PROFESSIONAL PARK DRIVE
Practice Address - Street 2:SIMCA
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:618-997-2161
Practice Address - Fax:618-997-2464
Is Sole Proprietor?:No
Enumeration Date:2010-05-06
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32561207Q00000X
IL036132187208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist