Basic Information
Provider Information | |||||||||
NPI: | 1295008340 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEONARD | ||||||||
FirstName: | KENDALL | ||||||||
MiddleName: | BLAINE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 90 LAKE DORNOCH DR | ||||||||
Address2: |   | ||||||||
City: | PINEHURST | ||||||||
State: | NC | ||||||||
PostalCode: | 283747109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9107151233 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 155 MEMORIAL DR | ||||||||
Address2: |   | ||||||||
City: | PINEHURST | ||||||||
State: | NC | ||||||||
PostalCode: | 283748710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9107151233 | ||||||||
FaxNumber: | 9106952282 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/21/2012 | ||||||||
LastUpdateDate: | 06/23/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0116024038 | VA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 390200000X |   | VA | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207L00000X | 2016-00829 | NC | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
No ID Information.