Healthcare Provider Details

I. General information

NPI: 1174315303
Provider Name (Legal Business Name): KENDALL HENDRICKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KENDALL LAVERTU

II. Dates (important events)

Enumeration Date: 05/22/2025
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 BICENTENNIAL HWY
SPRINGFIELD MA
01118-1962
US

IV. Provider business mailing address

305 BICENTENNIAL HWY
SPRINGFIELD MA
01118-1962
US

V. Phone/Fax

Practice location:
  • Phone: 413-733-4101
  • Fax:
Mailing address:
  • Phone: 413-733-4101
  • Fax: 413-783-9544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2334579
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: