Provider Demographics
NPI:1124748405
Name:CHRISTIDIS, KENDALL
Entity type:Individual
Prefix:
First Name:KENDALL
Middle Name:
Last Name:CHRISTIDIS
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 1:74 ECLIPSE CTR
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-3550
Mailing Address - Country:US
Mailing Address - Phone:608-361-0311
Mailing Address - Fax:608-361-0312
Practice Address - Street 1:74 ECLIPSE CTR
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-3550
Practice Address - Country:US
Practice Address - Phone:608-361-0311
Practice Address - Fax:608-361-0312
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209025846363LP0200X
WI14537-33363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics