Provider Demographics
NPI:1184351900
Name:BURGOON, KENDRA LEE
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:LEE
Last Name:BURGOON
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 1:1894 CHAPARRAL LOOP
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-3718
Mailing Address - Country:US
Mailing Address - Phone:575-838-8991
Mailing Address - Fax:575-838-0423
Practice Address - Street 1:801 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-4254
Practice Address - Country:US
Practice Address - Phone:575-838-8991
Practice Address - Fax:575-838-0423
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator