Provider Demographics
NPI:1447623236
Name:KING, KENDRA I
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:KING
Suffix:I
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 1:324 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:WI
Mailing Address - Zip Code:53956-1201
Mailing Address - Country:US
Mailing Address - Phone:608-239-0933
Mailing Address - Fax:608-242-1166
Practice Address - Street 1:5109 WORLD DAIRY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-3807
Practice Address - Country:US
Practice Address - Phone:608-242-0220
Practice Address - Fax:608-242-1166
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI312037-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse