Healthcare Provider Details

I. General information

NPI: 1871943142
Provider Name (Legal Business Name): KENDRA NICHOLE RAKES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KENDRA NICHOLE FISHER

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W 2ND ST
WELLSTON OH
45692-1435
US

IV. Provider business mailing address

844 RIDGELAND RD
JACKSON OH
45640-8604
US

V. Phone/Fax

Practice location:
  • Phone: 740-384-2174
  • Fax: 740-384-1685
Mailing address:
  • Phone: 740-577-8295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number400101070552062
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: