Provider Demographics
NPI:1699975565
Name:KENDRICK-JEFFERY, DIANE (RN)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:KENDRICK-JEFFERY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-1105
Mailing Address - Country:US
Mailing Address - Phone:131-396-1378
Mailing Address - Fax:131-396-1376
Practice Address - Street 1:2051 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-1105
Practice Address - Country:US
Practice Address - Phone:131-396-1378
Practice Address - Fax:131-396-1376
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704120743163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704120743OtherSTATE LICENSE NUMBER