Provider Demographics
NPI:1093058083
Name:VONDEREMBSE, KENDRA N (DO)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:N
Last Name:VONDEREMBSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W GRAND AVE STE 3003
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-4722
Mailing Address - Country:US
Mailing Address - Phone:937-294-3603
Mailing Address - Fax:937-294-3612
Practice Address - Street 1:425 W GRAND AVE STE 3003
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-4722
Practice Address - Country:US
Practice Address - Phone:937-294-3603
Practice Address - Fax:937-294-3612
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-28
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.012508207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0190281Medicaid
OH0190281Medicaid