Provider Demographics
NPI:1851899140
Name:KENNEDY, MARIE ANTOINETTE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:ANTOINETTE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 CEDAR ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8707
Mailing Address - Fax:574-335-0741
Practice Address - Street 1:611 E DOUGLAS RD STE 208
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1465
Practice Address - Country:US
Practice Address - Phone:574-335-6000
Practice Address - Fax:574-335-0738
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-01
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007869A363LG0600X, 363L00000X
IN28143781A363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology