Provider Demographics
NPI:1518928092
Name:SPONN, KENDRA K (PT)
Entity Type:Individual
Prefix:MS
First Name:KENDRA
Middle Name:K
Last Name:SPONN
Suffix:
Gender:F
Credentials:PT
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 358
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:IN
Mailing Address - Zip Code:46072-0358
Mailing Address - Country:US
Mailing Address - Phone:765-675-8119
Mailing Address - Fax:765-675-8257
Practice Address - Street 1:514 E STATE ROAD 32
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-8767
Practice Address - Country:US
Practice Address - Phone:877-366-2663
Practice Address - Fax:317-867-3798
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007791A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000361993OtherANTHEM ID
IN200513890Medicaid