Healthcare Provider Details

I. General information

NPI: 1124730924
Provider Name (Legal Business Name): KANESHA RAQUEL MCDOWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2022
Last Update Date: 12/31/2022
Certification Date: 12/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 TULLIE RD NE
ATLANTA GA
30329-2309
US

IV. Provider business mailing address

1619 MARSANNE TER NW
KENNESAW GA
30152-6768
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-5437
  • Fax:
Mailing address:
  • Phone: 229-894-6880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License NumberRN252289
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberRN252289
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: