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General NPI Number Information
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NPI Number | 1851899140
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Entity Type | Individual
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Provider Name | MARIE ANTOINETTE KENNEDY
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Gender | Female
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Dates
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Enumeration Date | 02/01/2018
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Last Update Date | 06/19/2024
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Provider Practice Location Address
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Address Line | 611 E DOUGLAS RD STE 208
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City | MISHAWAKA
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State | IN
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Zip | 46545-1465
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Country | US
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Telephone | 574-335-6000
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Fax | 574-335-0738
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Provider Business Mailing Address
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Address Line | 707 CEDAR ST STE 200
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City | SOUTH BEND
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State | IN
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Zip | 46617-2057
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Country | US
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Telephone | 574-335-8707
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Fax | 574-335-0741
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 71007869A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 28143781A
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 71007869A
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License Number State | IN
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