Provider Demographics
NPI:1316609233
Name:HAYDEN, KENDREK ALLEN
Entity type:Individual
Prefix:
First Name:KENDREK
Middle Name:ALLEN
Last Name:HAYDEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 N STOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-1746
Mailing Address - Country:US
Mailing Address - Phone:414-554-7570
Mailing Address - Fax:
Practice Address - Street 1:4215 N STOWELL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-1746
Practice Address - Country:US
Practice Address - Phone:414-554-7570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIH3505017912708172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver