Provider Demographics
NPI:1245864784
Name:LEONARD, KENDALL DIVANTE
Entity type:Individual
Prefix:
First Name:KENDALL
Middle Name:DIVANTE
Last Name:LEONARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3646 147TH PL APT GN
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:IL
Mailing Address - Zip Code:60445-3590
Mailing Address - Country:US
Mailing Address - Phone:708-690-4333
Mailing Address - Fax:
Practice Address - Street 1:524 N ROBERTS DR APT 2B
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:IL
Practice Address - Zip Code:60425-2300
Practice Address - Country:US
Practice Address - Phone:708-690-4333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILV00018705171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL11295611761Medicaid