Provider Demographics
NPI:1487799045
Name:STEWART, KENNETH (MA F-AAA)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:STEWART
Suffix:
Gender:M
Credentials:MA F-AAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5933 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-7636
Mailing Address - Country:US
Mailing Address - Phone:260-485-1231
Mailing Address - Fax:260-486-6958
Practice Address - Street 1:5933 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815
Practice Address - Country:US
Practice Address - Phone:260-485-1231
Practice Address - Fax:260-486-6958
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002245A237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN170770Medicare UPIN