1043261381 NPI number — KENDRA LYNNE CHURCH MS PA C

Table of content: KENDRA LYNNE CHURCH MS PA C (NPI 1043261381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043261381 NPI number — KENDRA LYNNE CHURCH MS PA C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHURCH
Provider First Name:
KENDRA
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS PA C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043261381
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 CHESTNUT STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STONEHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-921-8072
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44 BINNEY STREET
Provider Second Line Business Practice Location Address:
D1 B30
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02115-6084
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-525-7486
Provider Business Practice Location Address Fax Number:
617-278-6965
Provider Enumeration Date:
05/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  1388 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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