Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0200X | Nurse Practitioner - Pediatrics | RN164975 NP | GA |
NPI | 1003058249 |
---|---|
Provider Name | Ms. Philicia Kennedy |
First Address | Ellenwood, GA 30294-3693 |
Second Address | Ellenwood, GA 30294-3693 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/04/2009 |
Last Update Date | 02/04/2009 |