Healthcare Provider Details

I. General information

NPI: 1194636407
Provider Name (Legal Business Name): KENYADDA LANISE MCCLENDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10230 OKLAHOMA ST
BASTROP LA
71220-9750
US

IV. Provider business mailing address

10230 OKLAHOMA ST
BASTROP LA
71220-9750
US

V. Phone/Fax

Practice location:
  • Phone: 318-651-0086
  • Fax: 318-651-0087
Mailing address:
  • Phone: 318-651-0086
  • Fax: 318-651-0087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: