Healthcare Provider Details

I. General information

NPI: 1700527603
Provider Name (Legal Business Name): KENNEDY CHRISTINE NIES DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KENNEDY NIES

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2231 CAREW ST
FORT WAYNE IN
46805-4713
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-425-6780
  • Fax: 260-373-9225
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number11022744A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: