Provider Demographics
NPI:1801623483
Name:KENNARD, OCTAVIA LATRICE
Entity type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:LATRICE
Last Name:KENNARD
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 1:1022 BLAIR FIELD LN
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-8689
Mailing Address - Country:US
Mailing Address - Phone:337-570-8647
Mailing Address - Fax:
Practice Address - Street 1:1022 BLAIR FIELD LN
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:TX
Practice Address - Zip Code:77545-8689
Practice Address - Country:US
Practice Address - Phone:337-570-8647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNA726278376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide