Basic Information
| Provider Information | |||||||||
| NPI: | 1790011062 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNESON | ||||||||
| FirstName: | MARYANN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10881 SAN JOSE BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322236612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042603022 | ||||||||
| FaxNumber: | 9042603947 | ||||||||
| 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: | 10/21/2009 | ||||||||
| LastUpdateDate: | 02/13/2018 | ||||||||
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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 | 208800000X | 35098042 | OH | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | ME92864 | FL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0056336 | 05 | OH | MEDICAID | 14N6L | 01 | FL | BCBS | OTHER | 006734700 | 05 | FL | MEDICAID |