Provider Demographics
NPI:1508311069
Name:RUSSELL, KENDRA (LPN)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 N MICHIGAN AVE.
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036
Mailing Address - Country:US
Mailing Address - Phone:517-278-5933
Mailing Address - Fax:517-279-4946
Practice Address - Street 1:265 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-1528
Practice Address - Country:US
Practice Address - Phone:517-278-5933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703100039164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse