Healthcare Provider Details

I. General information

NPI: 1669707741
Provider Name (Legal Business Name): KENDRA HATTIE KALLEMEYN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 02/04/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 7TH AVE
LONGVIEW WA
98632-3166
US

IV. Provider business mailing address

500 NE MULTNOMAH ST
PORTLAND OR
97232-2023
US

V. Phone/Fax

Practice location:
  • Phone: 360-636-6238
  • Fax:
Mailing address:
  • Phone: 503-813-3860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3318
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3398-ATI
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD60431512
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: