Provider Demographics
NPI:1346718038
Name:KENDALL, JOANIE RUTH (PA-C)
Entity Type:Individual
Prefix:
First Name:JOANIE
Middle Name:RUTH
Last Name:KENDALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JOANIE
Other - Middle Name:RUTH
Other - Last Name:GAVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:407-284-6461
Mailing Address - Fax:
Practice Address - Street 1:200 E MARKS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-3819
Practice Address - Country:US
Practice Address - Phone:407-284-6460
Practice Address - Fax:407-284-6461
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111596363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM8468OtherMEDICARE