Healthcare Provider Details

I. General information

NPI: 1568431583
Provider Name (Legal Business Name): ANNA JOYCE KENNEL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 OAK RD
PLYMOUTH IN
46563-9757
US

IV. Provider business mailing address

328 N MICHIGAN ST SUITE 200
SOUTH BEND IN
46601-1244
US

V. Phone/Fax

Practice location:
  • Phone: 800-635-5516
  • Fax:
Mailing address:
  • Phone: 574-647-1069
  • Fax: 574-647-1825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71001010A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: