1518928092 NPI number — MS. KENDRA K SPONN PT

Table of content: MS. KENDRA K SPONN PT (NPI 1518928092)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518928092 NPI number — MS. KENDRA K SPONN PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPONN
Provider First Name:
KENDRA
Provider Middle Name:
K
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1518928092
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 358
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIPTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46072-0358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-675-8119
Provider Business Mailing Address Fax Number:
765-675-8257

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
514 E STATE ROAD 32
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTFIELD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46074-8767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-366-2663
Provider Business Practice Location Address Fax Number:
317-867-3798
Provider Enumeration Date:
03/31/2006

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: 225100000X , with the licence number:  05007791A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000361993 . This is a "ANTHEM ID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200513890 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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