Healthcare Provider Details

I. General information

NPI: 1861697187
Provider Name (Legal Business Name): KENDRA CELESTE CUNNINGHAM LPN, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1243 PINE ST
AUGUSTA GA
30901-3334
US

IV. Provider business mailing address

512 WEATHERLY DR
STONE MOUNTAIN GA
30083
US

V. Phone/Fax

Practice location:
  • Phone: 678-887-8706
  • Fax:
Mailing address:
  • Phone: 678-887-8706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number077864
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: