Provider Demographics
NPI:1669949319
Name:POULSEN, KENDRA JO (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:JO
Last Name:POULSEN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:KENDRA
Other - Middle Name:JO
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:HC 10 BOX 40
Mailing Address - Street 2:
Mailing Address - City:PIOCHE
Mailing Address - State:NV
Mailing Address - Zip Code:89043-9401
Mailing Address - Country:US
Mailing Address - Phone:208-589-2729
Mailing Address - Fax:
Practice Address - Street 1:297 NEVADA NORTHERN RAIL WAY STE 5
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:NV
Practice Address - Zip Code:89301-2807
Practice Address - Country:US
Practice Address - Phone:775-293-6558
Practice Address - Fax:775-289-1561
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRN95615163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health