Provider Demographics
NPI:1942454632
Name:BREITHAUPT, KENDRA MARKS (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:KENDRA
Middle Name:MARKS
Last Name:BREITHAUPT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 LAKERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-1015
Mailing Address - Country:US
Mailing Address - Phone:214-535-8109
Mailing Address - Fax:
Practice Address - Street 1:6331 PROSPECT AVENUE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214
Practice Address - Country:US
Practice Address - Phone:214-821-9161
Practice Address - Fax:214-824-1039
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-09
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX688058363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX267227YKY6Medicare PIN