Provider Demographics
NPI:1669433470
Name:DAVIS, KENDRA M (MD)
Entity type:Individual
Prefix:DR
First Name:KENDRA
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 BRETZ CT STE 100
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17074-8615
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 BRETZ CT STE 100
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:PA
Practice Address - Zip Code:17074-8615
Practice Address - Country:US
Practice Address - Phone:717-567-3174
Practice Address - Fax:717-703-0018
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD069404L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001772601Medicaid
PAP002004OtherGATEWAY
PA2231374OtherAETNA
PA02080802OtherBLUE CROSS/CAIC
PADA733802OtherHIGHMARK BLUE SHIELD
PA1831501OtherFIRST HEALTH
PA001772601001Medicaid
PA9072765OtherPHCS
PAP002004OtherGATEWAY