Provider Demographics
NPI:1689331365
Name:IVERSON, KENDALL MARIE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:MARIE
Last Name:IVERSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2464 FENTON PKWY APT 205
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-6705
Mailing Address - Country:US
Mailing Address - Phone:425-563-8103
Mailing Address - Fax:
Practice Address - Street 1:6264 FERRIS SQ
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3204
Practice Address - Country:US
Practice Address - Phone:619-940-4128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301230225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist