Basic Information
| Provider Information | |||||||||
| NPI: | 1023380128 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | KENDRA | ||||||||
| MiddleName: | GENELLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN, BSN, QMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3587 HEATHROW WAY | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038588170 | ||||||||
| FaxNumber: | 5418588167 | ||||||||
| Practice Location | |||||||||
| Address1: | 3587 HEATHROW WAY | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038588170 | ||||||||
| FaxNumber: | 5418588167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2012 | ||||||||
| LastUpdateDate: | 02/24/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 201142442RN | OR | Y | Nursing Service Providers | Registered Nurse | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 163WP0808X | 201142442RN | OR | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.