Healthcare Provider Details

I. General information

NPI: 1851899140
Provider Name (Legal Business Name): MARIE ANTOINETTE KENNEDY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2018
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 E DOUGLAS RD STE 208
MISHAWAKA IN
46545-1465
US

IV. Provider business mailing address

707 CEDAR ST STE 200
SOUTH BEND IN
46617-2057
US

V. Phone/Fax

Practice location:
  • Phone: 574-335-6000
  • Fax: 574-335-0738
Mailing address:
  • Phone: 574-335-8707
  • Fax: 574-335-0741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71007869A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number71007869A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number28143781A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: