Provider Demographics
NPI:1699400457
Name:MATHEWS, KENDRA SHIRLEY
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:SHIRLEY
Last Name:MATHEWS
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 1:5235 WHIPPLE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-3054
Mailing Address - Country:US
Mailing Address - Phone:248-390-9553
Mailing Address - Fax:
Practice Address - Street 1:10770 ELIZABETH LAKE RD
Practice Address - Street 2:
Practice Address - City:WHITE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48386-2136
Practice Address - Country:US
Practice Address - Phone:248-618-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-17
Last Update Date:2022-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000566208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation