Healthcare Provider Details

I. General information

NPI: 1225006216
Provider Name (Legal Business Name): KRISTIN KAE FENDEL D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W MAIN ST
MIDDLETON ID
83644-5637
US

IV. Provider business mailing address

111 W MAIN ST
MIDDLETON ID
83644-5637
US

V. Phone/Fax

Practice location:
  • Phone: 208-899-2856
  • Fax: 208-585-6431
Mailing address:
  • Phone: 510-329-1482
  • Fax: 208-585-6431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number13513
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA-1807
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: