Healthcare Provider Details

I. General information

NPI: 1790192284
Provider Name (Legal Business Name): REGINA MARIE KENDRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1686 W RIVERSTONE DR
COEUR D ALENE ID
83814-5779
US

IV. Provider business mailing address

1686 W RIVERSTONE DR
COEUR D ALENE ID
83814-5779
US

V. Phone/Fax

Practice location:
  • Phone: 208-762-0480
  • Fax: 866-573-0853
Mailing address:
  • Phone: 208-762-0480
  • Fax: 866-573-0853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP-1460A
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberAP60477652
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: