Provider Demographics
NPI:1639806888
Name:LITTLEFIELD, KENDALL MARIE
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:MARIE
Last Name:LITTLEFIELD
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 1:4430 KEENELAND LN UNIT 104
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1985
Mailing Address - Country:US
Mailing Address - Phone:219-476-6365
Mailing Address - Fax:
Practice Address - Street 1:5802 S ANTHONY BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46816-3702
Practice Address - Country:US
Practice Address - Phone:260-456-5518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN45022652A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program