Healthcare Provider Details

I. General information

NPI: 1952441552
Provider Name (Legal Business Name): KENDYL EDMAN HOUDYSHELL RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 12/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 N STATE ST
HEMET CA
92543-2960
US

IV. Provider business mailing address

43154 PARKWAY AVE
HEMET CA
92544-1731
US

V. Phone/Fax

Practice location:
  • Phone: 951-791-3300
  • Fax:
Mailing address:
  • Phone: 951-927-3478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN306259
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: