Healthcare Provider Details

I. General information

NPI: 1164122669
Provider Name (Legal Business Name): KELSEY RAEANN LEYENDEKKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 03/06/2023
Certification Date: 03/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8150 AVENUE 360
VISALIA CA
93291-8941
US

IV. Provider business mailing address

8150 AVENUE 360
VISALIA CA
93291-8941
US

V. Phone/Fax

Practice location:
  • Phone: 559-786-3104
  • Fax:
Mailing address:
  • Phone: 155-978-6310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number811610
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: