Provider Demographics
NPI:1386125383
Name:SAMUEL, KENDRA IESHA (FNP)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:IESHA
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1434 CENTRAL AVE E
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-9602
Mailing Address - Country:US
Mailing Address - Phone:601-928-6600
Mailing Address - Fax:
Practice Address - Street 1:1434 CENTRAL AVE E
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-9602
Practice Address - Country:US
Practice Address - Phone:601-928-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902802363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily