Provider Demographics
NPI:1417108408
Name:KENDRICK, TARYN RAE HOLLAWAY
Entity Type:Individual
Prefix:MRS
First Name:TARYN
Middle Name:RAE HOLLAWAY
Last Name:KENDRICK
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:PO BOX 176
Mailing Address - Street 2:
Mailing Address - City:CHEROKEE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:72525-0176
Mailing Address - Country:US
Mailing Address - Phone:870-257-3336
Mailing Address - Fax:870-257-3339
Practice Address - Street 1:#4 E CHEROKEE VILLAGE MALL
Practice Address - Street 2:
Practice Address - City:CHEROKEE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:72529
Practice Address - Country:US
Practice Address - Phone:870-257-3336
Practice Address - Fax:870-257-3339
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR167349526Medicaid