Provider Demographics
NPI:1316290893
Name:KENNEDY, KATHERINE EDITHE (DPM)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:EDITHE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1728 W GLENDALE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-8862
Mailing Address - Country:US
Mailing Address - Phone:480-812-3668
Mailing Address - Fax:480-782-1290
Practice Address - Street 1:1728 W GLENDALE AVE STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-8862
Practice Address - Country:US
Practice Address - Phone:480-812-3668
Practice Address - Fax:480-782-1290
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-20
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL135.000790213ES0103X
AZ0818213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ179475Medicaid