Provider Demographics
NPI:1669707741
Name:KALLEMEYN, KENDRA HATTIE (OD)
Entity type:Individual
Prefix:DR
First Name:KENDRA
Middle Name:HATTIE
Last Name:KALLEMEYN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 NE MULTNOMAH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2023
Mailing Address - Country:US
Mailing Address - Phone:503-813-3860
Mailing Address - Fax:
Practice Address - Street 1:1230 7TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3166
Practice Address - Country:US
Practice Address - Phone:360-636-6238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3318152W00000X
OR3398-ATI152W00000X
390200000X
WAOD60431512152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410003841Medicare PIN