Basic Information
| Provider Information | |||||||||
| NPI: | 1003398223 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEILL | ||||||||
| FirstName: | KENDAL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEISTER | ||||||||
| OtherFirstName: | KENDAL | ||||||||
| OtherMiddleName: | MCAULEY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 416 COLEGATE DR BLDG 3 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457509549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403743526 | ||||||||
| FaxNumber: | 7403743165 | ||||||||
| Practice Location | |||||||||
| Address1: | 608 2ND ST | ||||||||
| Address2: | |||||||||
| City: | NEW MATAMORAS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457671154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7408653419 | ||||||||
| FaxNumber: | 7408659966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2018 | ||||||||
| LastUpdateDate: | 08/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN.CNP.023248 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.