Healthcare Provider Details

I. General information

NPI: 1992253462
Provider Name (Legal Business Name): KENDRIA WERNER PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019 3RD AVE S
PAYETTE ID
83661-2832
US

IV. Provider business mailing address

1821 S JUNIPER ST APT. C24
NAMPA ID
83686-6176
US

V. Phone/Fax

Practice location:
  • Phone: 208-642-4455
  • Fax:
Mailing address:
  • Phone: 208-409-2179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4617
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: