Provider Demographics
NPI:1144525874
Name:WASHBURN, KENDALL DEREK (RN)
Entity type:Individual
Prefix:MR
First Name:KENDALL
Middle Name:DEREK
Last Name:WASHBURN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1515 NE LAWRIE TATUM RD
Mailing Address - Street 2:BUILDING 414
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-3002
Mailing Address - Country:US
Mailing Address - Phone:580-354-5562
Mailing Address - Fax:580-354-5563
Practice Address - Street 1:1515 NE LAWRIE TATUM RD
Practice Address - Street 2:BUILDING 414
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-3002
Practice Address - Country:US
Practice Address - Phone:580-354-5562
Practice Address - Fax:580-354-5563
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR83207172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker