Provider Demographics
NPI:1952601544
Name:CUNEGIN, KENDRA NICHOLE (OD)
Entity Type:Individual
Prefix:DR
First Name:KENDRA
Middle Name:NICHOLE
Last Name:CUNEGIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-0549
Mailing Address - Country:US
Mailing Address - Phone:260-569-9550
Mailing Address - Fax:260-569-0760
Practice Address - Street 1:7747 W JEFFERSON BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4135
Practice Address - Country:US
Practice Address - Phone:260-459-8444
Practice Address - Fax:260-459-8443
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003830152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201213330Medicaid
IN201213330Medicaid