Provider Demographics
NPI:1902267057
Name:KENNEDY, CRYSTAL NICOLE (NP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:NICOLE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1153 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706-2061
Mailing Address - Country:US
Mailing Address - Phone:260-222-1181
Mailing Address - Fax:260-333-0510
Practice Address - Street 1:1153 W 15TH ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-2061
Practice Address - Country:US
Practice Address - Phone:260-222-1181
Practice Address - Fax:260-333-0510
Is Sole Proprietor?:No
Enumeration Date:2016-03-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006117A363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ00659366OtherRAILROAD PTAN
IN201350820Medicaid
IN1902267057OtherANTHEM PTAN