1851899140 NPI number — MARIE ANTOINETTE KENNEDY

Table of content: MARIE ANTOINETTE KENNEDY (NPI 1851899140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851899140 NPI number — MARIE ANTOINETTE KENNEDY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENNEDY
Provider First Name:
MARIE
Provider Middle Name:
ANTOINETTE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1851899140
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
707 CEDAR ST STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46617-2057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-335-8707
Provider Business Mailing Address Fax Number:
574-335-0741

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
611 E DOUGLAS RD STE 208
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MISHAWAKA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46545-1465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-335-6000
Provider Business Practice Location Address Fax Number:
574-335-0738
Provider Enumeration Date:
02/01/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LG0600X , with the licence number:  28143781A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 71007869A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)