Healthcare Provider Details

I. General information

NPI: 1376801662
Provider Name (Legal Business Name): KERRY M GUERNSEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S MAIN ST SUITE 202
ELKHART IN
46516-3248
US

IV. Provider business mailing address

113 LINCOLNWAY E
MISHAWAKA IN
46544-2016
US

V. Phone/Fax

Practice location:
  • Phone: 574-255-4976
  • Fax: 574-255-1882
Mailing address:
  • Phone: 574-255-4976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: