Healthcare Provider Details

I. General information

NPI: 1366483638
Provider Name (Legal Business Name): KENDALL LEON BLACKWELL DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1704 GLENDALE DR SW SUITE A
WILSON NC
27893-4678
US

IV. Provider business mailing address

1704 GLENDALE DR SW
WILSON NC
27893-4678
US

V. Phone/Fax

Practice location:
  • Phone: 252-237-0138
  • Fax: 252-237-7903
Mailing address:
  • Phone: 252-237-0138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number238
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number238
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number238
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: