Provider Demographics
NPI:1912122847
Name:KENNEDY, CRISWELL ALLEN (MD)
Entity type:Individual
Prefix:
First Name:CRISWELL
Middle Name:ALLEN
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24128 E ALKI LN
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-9447
Mailing Address - Country:US
Mailing Address - Phone:509-255-5065
Mailing Address - Fax:509-477-6352
Practice Address - Street 1:24128 E ALKI LN
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-9447
Practice Address - Country:US
Practice Address - Phone:509-255-5065
Practice Address - Fax:509-477-6352
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00017804208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice