Healthcare Provider Details

I. General information

NPI: 1659294072
Provider Name (Legal Business Name): MELISSA J KENNEDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29913 RUNKLE ST
NILES MI
49120-6032
US

IV. Provider business mailing address

29913 RUNKLE ST
NILES MI
49120-6032
US

V. Phone/Fax

Practice location:
  • Phone: 269-591-0984
  • Fax:
Mailing address:
  • Phone: 269-591-0984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number28215038A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: