Provider Demographics
NPI:1538785191
Name:KENDALL, KAILEY JO
Entity type:Individual
Prefix:
First Name:KAILEY
Middle Name:JO
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 1:5591 W MARVIN LN APT 213
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-6232
Mailing Address - Country:US
Mailing Address - Phone:208-705-4339
Mailing Address - Fax:
Practice Address - Street 1:4840 N CLOVERDALE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-2423
Practice Address - Country:US
Practice Address - Phone:208-706-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP8839183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist