Provider Demographics
NPI:1790192284
Name:KENDRA, REGINA MARIE
Entity Type:Individual
Prefix:
First Name:REGINA MARIE
Middle Name:
Last Name:KENDRA
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 1:1686 W RIVERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-5779
Mailing Address - Country:US
Mailing Address - Phone:208-762-0480
Mailing Address - Fax:866-573-0853
Practice Address - Street 1:1686 W RIVERSTONE DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-5779
Practice Address - Country:US
Practice Address - Phone:208-762-0480
Practice Address - Fax:866-573-0853
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60477652364SF0001X
IDNP-1460A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health