MEDICARE: MARY KATHERINE FENNELLY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	13196	GA

General Provider Information

NPI Number	:	1356237077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY KATHERINE FENNELLY PA-C

Provider Business Mailing Address
First Line	:	1036 W NANCY CREEK DR NE
Second Line	:
City	:	BROOKHAVEN
State	:	GA
Zip	:	30319-1634
Country	:	US
Telephone Number	:	404-884-3585
Fax Number	:

Provider Business Practice Location Address
First Line	:	5670 PEACHTREE DUNWOODY RD STE 820
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-4717
Country	:	US
Telephone Number	:	404-851-1998
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2025
Last Update Date	:	08/25/2025

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