Healthcare Provider Details

I. General information

NPI: 1972030765
Provider Name (Legal Business Name): PAOLA JETZABELLA KENNAH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2349 VILLAGE SQUARE PKWY STE 110-111
FLEMING ISLAND FL
32003-6355
US

IV. Provider business mailing address

23343 NW COUNTY ROAD 236
HIGH SPRINGS FL
32643-9669
US

V. Phone/Fax

Practice location:
  • Phone: 904-385-2023
  • Fax: 904-385-2454
Mailing address:
  • Phone: 386-454-0698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9117136
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number139211
License Number StateAK
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9117136
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: