Provider Demographics
NPI:1720095276
Name:KENNEDY, SUSAN (DO)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 UNIVERSITY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-2355
Mailing Address - Country:US
Mailing Address - Phone:515-248-1447
Mailing Address - Fax:515-248-1440
Practice Address - Street 1:2353 SE 14TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50320-1109
Practice Address - Country:US
Practice Address - Phone:515-248-1400
Practice Address - Fax:515-248-1414
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02732207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA59346OtherMEDICARE PTAN
IA0162065Medicaid
IA0162065Medicaid