Provider Demographics
NPI:1770910184
Name:MANNING, KENDRA (PAC)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:MANNING
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KENDRA
Other - Middle Name:
Other - Last Name:KEARNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4959 W. BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641
Mailing Address - Country:US
Mailing Address - Phone:773-930-3642
Mailing Address - Fax:
Practice Address - Street 1:4959 W. BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641
Practice Address - Country:US
Practice Address - Phone:773-930-3642
Practice Address - Fax:773-930-3974
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004745363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant