Individual
KEVIN PENDLEBURY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CDE
Contact information
Practice address
MISSION RD, FORT HALL, ID 83203-0306
(208) 238-2400
(208) 238-5462
Mailing address
PO BOX 306, FORT HALL, ID 83203-0306
(208) 238-2400
(208) 238-5462
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
N31309
ID
163WD0400X
Diabetes Educator Registered Nurse
Primary
2061-0302
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003399100
—
ID
Enumeration date
03/12/2009
Last updated
03/12/2009
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