Provider Demographics
NPI:1871943142
Name:RAKES, KENDRA NICHOLE
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:NICHOLE
Last Name:RAKES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KENDRA
Other - Middle Name:NICHOLE
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:844 RIDGELAND RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-8604
Mailing Address - Country:US
Mailing Address - Phone:740-577-8295
Mailing Address - Fax:
Practice Address - Street 1:120 W 2ND ST
Practice Address - Street 2:
Practice Address - City:WELLSTON
Practice Address - State:OH
Practice Address - Zip Code:45692-1435
Practice Address - Country:US
Practice Address - Phone:740-384-2174
Practice Address - Fax:740-384-1685
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400101070552062183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician