Basic Information
| Provider Information | |||||||||
| NPI: | 1083634935 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | ELAINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1390 HERITAGE LN | ||||||||
| Address2: | PLEASANT VIEW APTS # 92 | ||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744642136 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 S BLISS AVE | ||||||||
| Address2: | PEDIATRICS CLINIC | ||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744642512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184583120 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 01/06/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 22124 | WV | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 2080A0000X | 34616 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 2080A0000X | 21310 | SC | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 2080A0000X | 044765 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 2080A0000X | 00022200 | AL | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 2080A0000X | MD0000010129 | TN | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
No ID Information.