Healthcare Provider Details

I. General information

NPI: 1164366803
Provider Name (Legal Business Name): NICOLE KENNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2026
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3632 N DEQUINCY ST
INDIANAPOLIS IN
46218-1639
US

IV. Provider business mailing address

3632 N DEQUINCY ST
INDIANAPOLIS IN
46218-1639
US

V. Phone/Fax

Practice location:
  • Phone: 317-701-0820
  • Fax:
Mailing address:
  • Phone: 317-701-0820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number334532651
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: