Healthcare Provider Details

I. General information

NPI: 1528980331
Provider Name (Legal Business Name): KELLIE KENNEDY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 W NEW YORK ST
INDIANAPOLIS IN
46222-4487
US

IV. Provider business mailing address

2930 W NEW YORK ST
INDIANAPOLIS IN
46222-4487
US

V. Phone/Fax

Practice location:
  • Phone: 316-960-0414
  • Fax:
Mailing address:
  • Phone: 316-960-0414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberCNA0402821
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: