Basic Information
| Provider Information | |||||||||
| NPI: | 1548292840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRATER-HOLT | ||||||||
| FirstName: | KENDRA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PRATER | ||||||||
| OtherFirstName: | KENDRA | ||||||||
| OtherMiddleName: | R | ||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 854 W JAMES CAMPBELL BLVD | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384014659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317229999 | ||||||||
| FaxNumber: | 9317222049 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 JV MANGUBAT DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | WAYNESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384852440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317229999 | ||||||||
| FaxNumber: | 9317222049 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 11/06/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APN0000011888 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 4135504 | 01 | TN | BCBS OF TN | OTHER | 3710089 | 05 | TN | MEDICAID | 3643558 | 05 | TN | MEDICAID |