Provider Demographics
NPI:1275579575
Name:STEPHENS, KENDELL (DO)
Entity Type:Individual
Prefix:DR
First Name:KENDELL
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1953 WATERFALL DR STE A
Mailing Address - Street 2:
Mailing Address - City:NAPPANEE
Mailing Address - State:IN
Mailing Address - Zip Code:46550-8961
Mailing Address - Country:US
Mailing Address - Phone:574-773-4101
Mailing Address - Fax:574-773-5483
Practice Address - Street 1:1953 WATERFALL DR STE A
Practice Address - Street 2:
Practice Address - City:NAPPANEE
Practice Address - State:IN
Practice Address - Zip Code:46550-8961
Practice Address - Country:US
Practice Address - Phone:574-773-4101
Practice Address - Fax:574-773-5483
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002819A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200487900Medicaid
IND16670Medicare UPIN
IN200487900Medicaid