Provider Demographics
NPI:1740949957
Name:MOSS, KENDRA E
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:E
Last Name:MOSS
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 1:1899 ORCHARD LAKE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SYLVAN LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48320-1775
Mailing Address - Country:US
Mailing Address - Phone:248-933-5512
Mailing Address - Fax:
Practice Address - Street 1:1899 ORCHARD LAKE RD STE 101
Practice Address - Street 2:
Practice Address - City:SYLVAN LAKE
Practice Address - State:MI
Practice Address - Zip Code:48320-1775
Practice Address - Country:US
Practice Address - Phone:248-933-5512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program