=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134873078
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNEDY WHEELER BA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2022
-----------------------------------------------------
Last Update Date | 02/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3285 122ND AVE
-----------------------------------------------------
City | ALLEGAN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49010-9511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-251-3299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 CROYDEN AVE APT 2101
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49009-3325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-914-9792
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------