Healthcare Provider Details

I. General information

NPI: 1427984582
Provider Name (Legal Business Name): WILLIAM KENNEBREW OWNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8019 GLENWAY DR APT 208
INDIANAPOLIS IN
46236-7915
US

IV. Provider business mailing address

8019 GLENWAY DR APT 208
INDIANAPOLIS IN
46236-7915
US

V. Phone/Fax

Practice location:
  • Phone: 317-679-4112
  • Fax:
Mailing address:
  • Phone: 317-679-4112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number25-019680-1
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: