Provider Demographics
NPI:1124574553
Name:KENKEL, CARRIE J
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:J
Last Name:KENKEL
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 1:1506 EDGINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ELDORA
Mailing Address - State:IA
Mailing Address - Zip Code:50627-1624
Mailing Address - Country:US
Mailing Address - Phone:641-939-7777
Mailing Address - Fax:641-939-7778
Practice Address - Street 1:1506 EDGINGTON AVE
Practice Address - Street 2:
Practice Address - City:ELDORA
Practice Address - State:IA
Practice Address - Zip Code:50627-1624
Practice Address - Country:US
Practice Address - Phone:641-939-7777
Practice Address - Fax:641-939-7778
Is Sole Proprietor?:No
Enumeration Date:2016-08-26
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA084170363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant