Provider Demographics
NPI:1720792617
Name:PAULEY, KENDRA ANN
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:ANN
Last Name:PAULEY
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 1:375 N WALL ST STE P510
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3492
Mailing Address - Country:US
Mailing Address - Phone:815-935-0750
Mailing Address - Fax:
Practice Address - Street 1:375 N WALL ST STE P510
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3492
Practice Address - Country:US
Practice Address - Phone:815-935-0750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-06
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041454399163W00000X
IL209027052363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse