Healthcare Provider Details

I. General information

NPI: 1215674841
Provider Name (Legal Business Name): KENDRA IRENE DESOTEL RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 05/16/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1328 W 5TH ST
DALLAS CITY IL
62330-1100
US

IV. Provider business mailing address

1328 W 5TH ST
DALLAS CITY IL
62330-1100
US

V. Phone/Fax

Practice location:
  • Phone: 309-337-0703
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number110838
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: