Healthcare Provider Details

I. General information

NPI: 1972209633
Provider Name (Legal Business Name): KENDRA LATRICE MCCRACKEN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2023
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16044 COUNTY ROAD 165
TYLER TX
75703-7302
US

IV. Provider business mailing address

1135 E 6TH ST
TYLER TX
75701-4502
US

V. Phone/Fax

Practice location:
  • Phone: 903-526-5599
  • Fax:
Mailing address:
  • Phone: 903-426-1338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2053476
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: