1710242755 NPI number — KENDRA ADKISSON APRN,CNM

Table of content: KENDRA ADKISSON APRN,CNM (NPI 1710242755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710242755 NPI number — KENDRA ADKISSON APRN,CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ADKISSON
Provider First Name:
KENDRA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN,CNM
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:
1710242755
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 936
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONDON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40743-0936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-330-7840
Provider Business Mailing Address Fax Number:
606-330-7825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170 N EAGLE CREEK DR
Provider Second Line Business Practice Location Address:
STE 104
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40509-9087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-967-5848
Provider Business Practice Location Address Fax Number:
859-967-5473
Provider Enumeration Date:
07/05/2012

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: 367A00000X , with the licence number:  3007509 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100215590 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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