Provider Demographics
NPI:1700480662
Name:POOLE, KENDRA MAE (APRN FNP-C)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:MAE
Last Name:POOLE
Suffix:
Gender:F
Credentials:APRN FNP-C
Other - Prefix:
Other - First Name:KENDRA
Other - Middle Name:MAE
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2215 STATE ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-3465
Mailing Address - Country:US
Mailing Address - Phone:815-303-4668
Mailing Address - Fax:
Practice Address - Street 1:334 BACKBONE RD E
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-9685
Practice Address - Country:US
Practice Address - Phone:815-303-4668
Practice Address - Fax:949-862-8061
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-22
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.021604363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily