Healthcare Provider Details

I. General information

NPI: 1427548494
Provider Name (Legal Business Name): JEREMY KINNEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N 16TH ST
NEW CASTLE IN
47362
US

IV. Provider business mailing address

5365 N 25 W
GREENFIELD IN
46140-7239
US

V. Phone/Fax

Practice location:
  • Phone: 765-521-0890
  • Fax:
Mailing address:
  • Phone: 317-414-8283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28167056A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71008177A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71008177A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: