Provider Demographics
NPI:1194578302
Name:FOREST, KENNEDY ANN
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:ANN
Last Name:FOREST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KENNEDY
Other - Middle Name:ANN
Other - Last Name:KIRSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1555 N KEPP CT
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-4400
Mailing Address - Country:US
Mailing Address - Phone:605-484-5807
Mailing Address - Fax:
Practice Address - Street 1:1400 W 22ND ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1554
Practice Address - Country:US
Practice Address - Phone:605-484-5807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program