Provider Demographics
NPI:1750481149
Name:WIESEL, KENDRA BETH (CNM)
Entity type:Individual
Prefix:MRS
First Name:KENDRA
Middle Name:BETH
Last Name:WIESEL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MS
Other - First Name:KENDRA
Other - Middle Name:BETH
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:280 CHESTNUT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-1001
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:
Practice Address - Street 1:3300 MAIN ST
Practice Address - Street 2:4TH FLOOR, SUITE D
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1112
Practice Address - Country:US
Practice Address - Phone:413-794-7045
Practice Address - Fax:413-794-7345
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000265367A00000X
MA254280367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife