Basic Information
| Provider Information | |||||||||
| NPI: | 1992191662 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | W180N8000 TOWN HALL RD | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530514002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625323700 | ||||||||
| FaxNumber: | 2625323725 | ||||||||
| Practice Location | |||||||||
| Address1: | W180N8000 TOWN HALL RD | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530514002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625323700 | ||||||||
| FaxNumber: | 2625323725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2015 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 69210-20 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1992191662 | 05 | WI | MEDICAID |