Provider Demographics
NPI:1578550158
Name:KENDRICK, MALINDA K (FNP)
Entity Type:Individual
Prefix:
First Name:MALINDA
Middle Name:K
Last Name:KENDRICK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 S HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:MO
Mailing Address - Zip Code:65712-1407
Mailing Address - Country:US
Mailing Address - Phone:417-466-4110
Mailing Address - Fax:417-466-4255
Practice Address - Street 1:108 S HICKORY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-1407
Practice Address - Country:US
Practice Address - Phone:417-466-4110
Practice Address - Fax:417-466-4255
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000151234363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00115364OtherRR MEDICARE
MO427473806Medicaid
MO1578550158Medicaid
MO1578550158Medicaid
817530115Medicare ID - Type Unspecified