Healthcare Provider Details

I. General information

NPI: 1467849794
Provider Name (Legal Business Name): KENDRA DEWBERRY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 WALNUT ST
TEXARKANA AL
71854
US

IV. Provider business mailing address

503 WALNUT ST
TEXARKANA AR
71854-5286
US

V. Phone/Fax

Practice location:
  • Phone: 870-773-2108
  • Fax:
Mailing address:
  • Phone: 870-773-2108
  • Fax: 870-772-2752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA004369
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP127959
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: