Provider Demographics
NPI:1083059224
Name:MUKENDI, KUDITSHINI KAKESE (IDC)
Entity Type:Individual
Prefix:
First Name:KUDITSHINI
Middle Name:KAKESE
Last Name:MUKENDI
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 BLVD DE FRANCE
Mailing Address - Street 2:
Mailing Address - City:PARRIS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29905
Mailing Address - Country:US
Mailing Address - Phone:843-228-2111
Mailing Address - Fax:
Practice Address - Street 1:8829 SPECTRUM CENTER BLVD
Practice Address - Street 2:APT 3111
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1457
Practice Address - Country:US
Practice Address - Phone:843-228-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
1710/1002XOtherIDC