Basic Information
| Provider Information | |||||||||
| NPI: | 1285983098 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARY ANN KENNESON, M.D., LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1895 KINGSLEY AVE STE 903 | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320734410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046448353 | ||||||||
| FaxNumber: | 9046448289 | ||||||||
| Practice Location | |||||||||
| Address1: | 1895 KINGSLEY AVE STE 903 | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320734410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046448353 | ||||||||
| FaxNumber: | 9046448289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2012 | ||||||||
| LastUpdateDate: | 03/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | KENNESON | ||||||||
| AuthorizedOfficialFirstName: | MARYANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8594213759 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME92864 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.