Basic Information
| Provider Information | |||||||||
| NPI: | 1225562556 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KENDRICK | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | BROOKE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 610 W 158TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100327104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6062051288 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 610 W 158TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100327104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125441880 | ||||||||
| FaxNumber: | 2125441870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2017 | ||||||||
| LastUpdateDate: | 07/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD048387 | DC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | H0089976 | MD | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 311014-01 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.