Provider Demographics
NPI:1205334463
Name:FUSTIN, KENDRA R
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:R
Last Name:FUSTIN
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 1:1996 YELLOWFIN DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-3016
Mailing Address - Country:US
Mailing Address - Phone:210-850-2024
Mailing Address - Fax:
Practice Address - Street 1:3875 YORKTOWNE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-6051
Practice Address - Country:US
Practice Address - Phone:386-465-3378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17370235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist