Provider Demographics
NPI:1174403257
Name:PEBWORTH, KENDA
Entity type:Individual
Prefix:
First Name:KENDA
Middle Name:
Last Name:PEBWORTH
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 1:37596 COUNTY ROAD 1740
Mailing Address - Street 2:
Mailing Address - City:COALGATE
Mailing Address - State:OK
Mailing Address - Zip Code:74538-5054
Mailing Address - Country:US
Mailing Address - Phone:580-740-7968
Mailing Address - Fax:
Practice Address - Street 1:103 E CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:COALGATE
Practice Address - State:OK
Practice Address - Zip Code:74538-3436
Practice Address - Country:US
Practice Address - Phone:580-740-7968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator