Provider Demographics
NPI:1194222844
Name:KENNEDY, KELSEY REAL
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:REAL
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:CAITLIN
Other - Last Name:REAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:252 INVERNESS CENTER DR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-4834
Practice Address - Country:US
Practice Address - Phone:205-997-2966
Practice Address - Fax:205-379-6842
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.43941207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery