Provider Demographics
NPI:1902155583
Name:KENDALL, KEYSHA RAE
Entity Type:Individual
Prefix:
First Name:KEYSHA
Middle Name:RAE
Last Name:KENDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4528 SE ROETHE RD
Mailing Address - Street 2:APARTMENT 51
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267
Mailing Address - Country:US
Mailing Address - Phone:503-686-0756
Mailing Address - Fax:
Practice Address - Street 1:1500 NE IRVING ST
Practice Address - Street 2:SUITE 250
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232
Practice Address - Country:US
Practice Address - Phone:503-233-4356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6560340390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program