Provider Demographics
NPI:1992071377
Name:KENNEDY, KELLY (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3745 11TH CIR STE 101
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4838
Mailing Address - Country:US
Mailing Address - Phone:772-567-6412
Mailing Address - Fax:321-567-4991
Practice Address - Street 1:3745 11TH CIR STE 101
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4838
Practice Address - Country:US
Practice Address - Phone:772-567-6412
Practice Address - Fax:321-567-4991
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI65523207VX0000X
FLME160223207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100058166Medicaid