Provider Demographics
NPI:1639750565
Name:KIMBER, KENDRA LEE
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:LEE
Last Name:KIMBER
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 1:424 CLEVELAND BLVD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1108
Mailing Address - Country:US
Mailing Address - Phone:315-420-0983
Mailing Address - Fax:
Practice Address - Street 1:621 E BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-4254
Practice Address - Country:US
Practice Address - Phone:315-800-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066327-01183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist