Healthcare Provider Details

I. General information

NPI: 1538761358
Provider Name (Legal Business Name): KENDRA L WITHROW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 ETERNITY LN
GALLIPOLIS FERRY WV
25515-6616
US

IV. Provider business mailing address

5088 WASHINGTON ST W
CHARLESTON WV
25313-1536
US

V. Phone/Fax

Practice location:
  • Phone: 304-675-6869
  • Fax:
Mailing address:
  • Phone: 681-217-2081
  • Fax: 681-217-2104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: