In this study, fish farmers’ management practices, occurrence, and knowledge of fish diseases in Nyeri County, Kenya, were evaluated. Fish farming management practices for small-scale farmers in Kenya have numerous challenges which have led to disease occurrence and reduced production. Moreover, the impact and association of these challenges to farmers’ knowledge of fish diseases and their burden has not been fully studied. A semistructured questionnaire was used to capture farmers’ biodata, fish species farmed, and farmers’ management practices such as handling of nets, pond fertilization, and disposal of fish waste. Farmers’ knowledge of fish diseases was based on their ability to identify independent and dependent variable indicators. Independent variables included clinical signs, decreased feeding, bulging eyes, floating on water, abdominal swelling, bulging eyes, abnormal skin color, reduced growth, and abnormal swimming with fish death as were the dependent variable. A total of 208 farmers were interviewed and included those of tilapia (134), mixed tilapia and catfish (40), catfish (22), rainbow trout, and five dams under cooperative management. Tilapia was the most kept fish species (66.8%) followed by polyculture of tilapia and catfish (20%) and rainbow trout (2%). Most respondents were male (78.5%) over 51 years of age (50%). Fifty percent of the respondents had secondary school education. There was a significant association between deaths and sharing of nets in Kieni East subcounty (
p
=
0.0049
, chi-square), while on-farm fish waste disposing appeared to cause higher deaths compared to burning of the waste although not statistically significant (
p
=
0.13
). Few respondents observed decreased feed uptake (<20%) and poor growth. Fifty-seven percent of farmers reported mortalities. Fish poor growth, floating in water, and management practices in subcounties had significant effect on fish deaths. The farmers had knowledge of signs of diseased fish, but there was paucity of knowing the specific causes of disease. Farmers need to be empowered on best aquaculture husbandry to avoid disease transmission and specific fish disease signs to enhance proper reporting of disease for subsequent mitigation measures.