Healthcare Provider Details

I. General information

NPI: 1205767563
Provider Name (Legal Business Name): KENDRA BLACK LVN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2531 W WOODLAND DR
ANAHEIM CA
92801-2637
US

IV. Provider business mailing address

2531 W WOODLAND DR
ANAHEIM CA
92801-2637
US

V. Phone/Fax

Practice location:
  • Phone: 714-226-9888
  • Fax:
Mailing address:
  • Phone: 714-226-9888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number693557
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: