Healthcare Provider Details

I. General information

NPI: 1225525017
Provider Name (Legal Business Name): KENDRA KELLY MARTINEZ MD, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KENDRA MARIE KELLY

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 06/27/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

IV. Provider business mailing address

2450 RIVERSIDE AVE ACADEMIC OFFICE BUILDING, AO-401
MINNEAPOLIS MN
55454
US

V. Phone/Fax

Practice location:
  • Phone: 612-626-0644
  • Fax:
Mailing address:
  • Phone: 612-626-0644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberU2261
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number69028
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: