MEDICARE: AHTYANNA KENDRICK CPNP-PC

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	363LP0200X	Pediatric Nurse Practitioner	RN308162	GA

General Provider Information

NPI Number	:	1437830775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AHTYANNA KENDRICK CPNP-PC

Provider Business Mailing Address
First Line	:	3725 PRINCETON LAKES PKWY SW APT 1002
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-5533
Country	:	US
Telephone Number	:	229-854-3890
Fax Number	:

Provider Business Practice Location Address
First Line	:	626 DALLAS HWY
Second Line	:
City	:	VILLA RICA
State	:	GA
Zip	:	30180-1209
Country	:	US
Telephone Number	:	770-459-9378
Fax Number	:

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

Provider Enumeration Date	:	07/28/2023
Last Update Date	:	07/28/2023

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