Healthcare Provider Details

I. General information

NPI: 1063217206
Provider Name (Legal Business Name): KENDRA CRUICKSHANK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3576 COVINGTON HWY # 103
DECATUR GA
30032-1834
US

IV. Provider business mailing address

3576 COVINGTON HWY STE 103
DECATUR GA
30032-1834
US

V. Phone/Fax

Practice location:
  • Phone: 470-518-6287
  • Fax: 470-275-0684
Mailing address:
  • Phone: 470-518-6287
  • Fax: 470-275-0684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: