Healthcare Provider Details

I. General information

NPI: 1831496710
Provider Name (Legal Business Name): LEAH C KINNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2011
Last Update Date: 02/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 N LAFAYETTE BLVD
SOUTH BEND IN
46601-1003
US

IV. Provider business mailing address

130 S MAIN ST SUITE 250
SOUTH BEND IN
46601-1816
US

V. Phone/Fax

Practice location:
  • Phone: 574-232-2037
  • Fax: 574-232-1420
Mailing address:
  • Phone: 574-251-2100
  • Fax: 574-251-2151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number28161643A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: