Healthcare Provider Details

I. General information

NPI: 1629830740
Provider Name (Legal Business Name): KENDALL SCOTT NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2024
Last Update Date: 07/25/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 JESSE HILL JR DR SE
ATLANTA GA
30303-3031
US

IV. Provider business mailing address

80 JESSE HILL JR DR SE
ATLANTA GA
30303-3050
US

V. Phone/Fax

Practice location:
  • Phone: 404-616-1000
  • Fax:
Mailing address:
  • Phone: 404-616-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberNCO-000003
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN299525
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: