Healthcare Provider Details

I. General information

NPI: 1700529013
Provider Name (Legal Business Name): KENDRA BOLDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2022
Last Update Date: 07/29/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

784 MEDINA RD STE 107
MEDINA OH
44256-9634
US

IV. Provider business mailing address

784 MEDINA RD STE 107
MEDINA OH
44256-9634
US

V. Phone/Fax

Practice location:
  • Phone: 330-591-9635
  • Fax:
Mailing address:
  • Phone: 330-591-9635
  • Fax: 330-591-4150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number00000000000
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: