Provider Demographics
NPI:1295513232
Name:KENNEDY, KUNTA
Entity type:Individual
Prefix:
First Name:KUNTA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 W OGLETHORPE AVE APT 15
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-4162
Mailing Address - Country:US
Mailing Address - Phone:229-291-8311
Mailing Address - Fax:
Practice Address - Street 1:2024 W OGLETHORPE AVE APT 15
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-4162
Practice Address - Country:US
Practice Address - Phone:229-291-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047597856171W00000X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No171W00000XOther Service ProvidersContractor