Provider Demographics
NPI:1225599707
Name:LE, KENDRA JOHANNA (DO)
Entity Type:Individual
Prefix:DR
First Name:KENDRA
Middle Name:JOHANNA
Last Name:LE
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 1:4301 BROADWAY
Mailing Address - Street 2:CPO #121
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7615 KENNEDY CIRCLE
Practice Address - Street 2:BLDG. 1
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78235
Practice Address - Country:US
Practice Address - Phone:210-619-7105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2019-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXBP10068083390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program