MEDICARE: KENDEL NICOLE BENNETT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	190537	OR
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1912455205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENDEL NICOLE BENNETT

Provider Business Mailing Address
First Line	:	3155 SW MOODY AVE APT 219
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97239-4703
Country	:	US
Telephone Number	:	303-947-1277
Fax Number	:

Provider Business Practice Location Address
First Line	:	2095 EXCHANGE ST STE 301
Second Line	:
City	:	ASTORIA
State	:	OR
Zip	:	97103-3400
Country	:	US
Telephone Number	:	503-338-4087
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2016
Last Update Date	:	01/03/2019

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