Provider Demographics
NPI:1437408093
Name:BACK, KENDRA JO (ARNP)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:JO
Last Name:BACK
Suffix:
Gender:
Credentials:ARNP
Other - Prefix:
Other - First Name:KENDRA
Other - Middle Name:JO
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1490
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-0682
Mailing Address - Country:US
Mailing Address - Phone:828-262-3886
Mailing Address - Fax:833-665-5329
Practice Address - Street 1:448 CRANBERRY ST
Practice Address - Street 2:
Practice Address - City:NEWLAND
Practice Address - State:NC
Practice Address - Zip Code:28657-8800
Practice Address - Country:US
Practice Address - Phone:828-737-0221
Practice Address - Fax:828-737-0321
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28417363LF0000X
COAPN.0991706-NP363LF0000X
IL041572779363LP0808X
GARN297601363LP0808X
NC5021586363LF0000X
FLARNP9212674363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA297601OtherSTATE OF GA APRN LICENSE
FLARNP9212674OtherSTATE OF FLORIDA ARNP LICENSE
NC5021586OtherSTATE OF NC APRN
FLY0EZQOtherFLORIDA BLUE-BCBS
CO65122071Medicaid
IL041572779OtherSTATE OF IL APRN LICENSE