Provider Demographics
NPI:1982053112
Name:KENNEDY, BRIAN ROBERT (DNP)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ROBERT
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 W SOUTHCREST CIR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-3158
Mailing Address - Country:US
Mailing Address - Phone:314-346-5204
Mailing Address - Fax:
Practice Address - Street 1:4102 PINION DR
Practice Address - Street 2:
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840-2502
Practice Address - Country:US
Practice Address - Phone:719-524-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011099171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider