MEDICARE: KENDALL ELLINGTON ESSEX FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	AP07824	LA
2	363LF0000X	Family Nurse Practitioner	AP133526	TX

General Provider Information

NPI Number	:	1114333028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENDALL ELLINGTON ESSEX FNP

Provider Business Mailing Address
First Line	:	3907 S SHERWOOD FRST
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-4363
Country	:	US
Telephone Number	:	225-367-6189
Fax Number	:	225-456-2301

Provider Business Practice Location Address
First Line	:	3907 S SHERWOOD FOREST BLVD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-4363
Country	:	US
Telephone Number	:	225-367-6189
Fax Number	:	225-456-2301

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2014
Last Update Date	:	06/11/2017

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