Provider Demographics
NPI:1477279289
Name:BIRDSONG, KENDRICE RAVEN
Entity Type:Individual
Prefix:
First Name:KENDRICE
Middle Name:RAVEN
Last Name:BIRDSONG
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 1:9 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-2113
Mailing Address - Country:US
Mailing Address - Phone:601-493-3904
Mailing Address - Fax:
Practice Address - Street 1:118 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39406-0002
Practice Address - Country:US
Practice Address - Phone:601-445-0879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program