Provider Demographics
NPI:1861415762
Name:LAWRENCE, KENDRA STOUT (MD)
Entity type:Individual
Prefix:DR
First Name:KENDRA
Middle Name:STOUT
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 745254
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-5254
Mailing Address - Country:US
Mailing Address - Phone:773-352-1519
Mailing Address - Fax:312-929-0373
Practice Address - Street 1:179 COLUMBUS BLVD
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-2264
Practice Address - Country:US
Practice Address - Phone:860-356-2557
Practice Address - Fax:860-261-0839
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT039642207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004179033Medicaid
CT004179033Medicaid
110008329Medicare ID - Type Unspecified