Provider Demographics
NPI:1851833222
Name:KIDWELL, CASSANDR
Entity Type:Individual
Prefix:
First Name:CASSANDR
Middle Name:
Last Name:KIDWELL
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 1:2945 GARDNERSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CRITTENDEN
Mailing Address - State:KY
Mailing Address - Zip Code:41030-8244
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2945 GARDNERSVILLE RD
Practice Address - Street 2:
Practice Address - City:CRITTENDEN
Practice Address - State:KY
Practice Address - Zip Code:41030-8244
Practice Address - Country:US
Practice Address - Phone:859-462-4508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2552670385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2552670Medicaid