Provider Demographics
NPI:1336364850
Name:MARTIN, KENDRA SHAUN (MSPT)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:SHAUN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:499 SE 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-7738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1535 S IVY ST
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-4334
Practice Address - Country:US
Practice Address - Phone:503-266-5541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2018-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9053225100000X
WAPT 60058447225100000X
OR6941225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist