Provider Demographics
NPI:1902460504
Name:KENNEDY, COLLEEN RENEE
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:RENEE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 BEMIS HEIGHTS PL
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-1752
Mailing Address - Country:US
Mailing Address - Phone:636-697-4793
Mailing Address - Fax:
Practice Address - Street 1:9300 VALLEY CHILDRENS PL
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-8762
Practice Address - Country:US
Practice Address - Phone:559-353-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS