Provider Demographics
NPI:1891479960
Name:KNAGA, KENDRA
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:KNAGA
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 1:1 HAIRPIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62026-0001
Mailing Address - Country:US
Mailing Address - Phone:618-650-5688
Mailing Address - Fax:
Practice Address - Street 1:85 BROOKSIDE
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:IL
Practice Address - Zip Code:62924-3900
Practice Address - Country:US
Practice Address - Phone:630-649-0542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041356464163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine