Provider Demographics
NPI:1285983098
Name:MARY ANN KENNESON, M.D., LLC
Entity type:Organization
Organization Name:MARY ANN KENNESON, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYANN
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNESON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-421-3759
Mailing Address - Street 1:1895 KINGSLEY AVE STE 903
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4410
Mailing Address - Country:US
Mailing Address - Phone:904-644-8353
Mailing Address - Fax:904-644-8289
Practice Address - Street 1:1895 KINGSLEY AVE STE 903
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4410
Practice Address - Country:US
Practice Address - Phone:904-644-8353
Practice Address - Fax:904-644-8289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-07
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92864174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty