Provider Demographics
NPI:1992314231
Name:GOTTULA, KENDRA ANN (LPN)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:ANN
Last Name:GOTTULA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1829 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NE
Mailing Address - Zip Code:68305-1713
Mailing Address - Country:US
Mailing Address - Phone:402-274-4328
Mailing Address - Fax:
Practice Address - Street 1:1829 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NE
Practice Address - Zip Code:68305-1713
Practice Address - Country:US
Practice Address - Phone:402-274-4328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE20425164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty