Provider Demographics
NPI:1801177621
Name:BLACKEAGLE, KENDRA SCHERRIE (CRNA)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:SCHERRIE
Last Name:BLACKEAGLE
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:KENDRA
Other - Middle Name:S
Other - Last Name:WILKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:920 CHURCH ST N
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2927
Mailing Address - Country:US
Mailing Address - Phone:704-403-2715
Mailing Address - Fax:704-699-2453
Practice Address - Street 1:920 CHURCH ST N
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2927
Practice Address - Country:US
Practice Address - Phone:704-403-2715
Practice Address - Fax:704-699-2453
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704287475367500000X
NC328087367500000X
NC6506367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1801177621OtherINDIVIDUAL
MI4704287475OtherMI LICENSE