Provider Demographics
NPI:1831328848
Name:KENNEDY, KRYSTLE LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:KRYSTLE
Middle Name:LYNN
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 1:7615 DODGE ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-3634
Mailing Address - Country:US
Mailing Address - Phone:402-391-2375
Mailing Address - Fax:402-397-0371
Practice Address - Street 1:7615 DODGE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114
Practice Address - Country:US
Practice Address - Phone:402-391-2375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-11
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1327152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist