Basic Information
| Provider Information | |||||||||
| NPI: | 1780166421 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNEDY | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | RN, MSN, FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8382 N MARYS LN | ||||||||
| Address2: | |||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463507027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193801591 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 EAST BLVD | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465142483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5743897393 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2018 | ||||||||
| LastUpdateDate: | 08/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 28195168A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 28195168A | 01 | IN | INDIANA STATE BOARD OF NURSING | OTHER |