Basic Information
| Provider Information | |||||||||
| NPI: | 1114670965 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENERY | ||||||||
| FirstName: | KENDALL | ||||||||
| MiddleName: | EILEEN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1340 ELSER DR SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973021861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035593362 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5050 SKYLINE VILLAGE LOOP S | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973069490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033911110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2022 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207Q00000X | PA206842 | OR | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.