Healthcare Provider Details

I. General information

NPI: 1609131598
Provider Name (Legal Business Name): KENDRA RACHELLE NULL O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KENDRA RACHELLE DALTON O.D.

II. Dates (important events)

Enumeration Date: 07/07/2012
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 E LINWOOD BLVD
KANSAS CITY MO
64128-2226
US

IV. Provider business mailing address

594 CALLA LILLY WAY
TIFFIN IA
52340-9236
US

V. Phone/Fax

Practice location:
  • Phone: 816-861-4700
  • Fax: 816-922-3382
Mailing address:
  • Phone: 901-483-5633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number089984
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3063
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2015035194
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: