Provider Demographics
NPI:1720080633
Name:NIEKAMP, KENDRA
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:NIEKAMP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2216 AUBURN DR
Mailing Address - Street 2:
Mailing Address - City:ST MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-3301
Mailing Address - Country:US
Mailing Address - Phone:419-305-3448
Mailing Address - Fax:
Practice Address - Street 1:1052 E SPRING ST
Practice Address - Street 2:
Practice Address - City:ST MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-2446
Practice Address - Country:US
Practice Address - Phone:419-394-3219
Practice Address - Fax:419-394-6289
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH030118830183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist