Provider Demographics
NPI:1053320549
Name:KENDALL, CONNIE SUE
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:SUE
Last Name:KENDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 PRO-MED LN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5317
Mailing Address - Country:US
Mailing Address - Phone:317-843-9922
Mailing Address - Fax:317-581-3918
Practice Address - Street 1:703 PRO-MED LN
Practice Address - Street 2:SUITE 200
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5317
Practice Address - Country:US
Practice Address - Phone:317-843-9922
Practice Address - Fax:317-581-3918
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000714A364S00000X
IN70000174A364SP0809X, 364SP0811X, 364SP0812X, 364SR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No364SP0811XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Chronically Ill
No364SP0812XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Community
No364SR0400XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200852470Medicaid
IN100270530AMedicaid
IN798900DDMedicare PIN