Provider Demographics
NPI:1417107657
Name:KENDALL, KIMBERLY L (PA)
Entity Type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:L
Last Name:KENDALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3311 E MURDOCK ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-3054
Mailing Address - Country:US
Mailing Address - Phone:316-689-9335
Mailing Address - Fax:
Practice Address - Street 1:3311 E MURDOCK ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3054
Practice Address - Country:US
Practice Address - Phone:316-689-9335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-00260363AM0700X
KS15-01301363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS003719177Medicare Oscar/Certification