Provider Demographics
NPI:1437406485
Name:KENDRICK, TERESA D (NP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:D
Last Name:KENDRICK
Suffix:
Gender:F
Credentials:NP
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 588
Mailing Address - Street 2:
Mailing Address - City:NESBIT
Mailing Address - State:MS
Mailing Address - Zip Code:38651-0588
Mailing Address - Country:US
Mailing Address - Phone:662-649-6502
Mailing Address - Fax:662-228-7893
Practice Address - Street 1:5699 GETWELL RD, SUITE 5
Practice Address - Street 2:BUILDING F
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-7312
Practice Address - Country:US
Practice Address - Phone:662-649-6502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-09
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR803535163WP0809X
MS803535363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00600734Medicaid