Provider Demographics
NPI:1619393659
Name:KENNEDY, STEPHANIE (RN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:S
Other - Last Name:STASZAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:164 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2728
Mailing Address - Country:US
Mailing Address - Phone:920-965-4055
Mailing Address - Fax:
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:STE 330
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54308-8900
Practice Address - Country:US
Practice Address - Phone:920-288-8350
Practice Address - Fax:920-288-8355
Is Sole Proprietor?:No
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI120176163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse