Healthcare Provider Details

I. General information

NPI: 1164040036
Provider Name (Legal Business Name): KENNETH KEITH WOODINGTON APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KENNETH KEITH BULLINGTON APRN

II. Dates (important events)

Enumeration Date: 07/08/2020
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 N DECATUR RD STE 200
DECATUR GA
30033-6132
US

IV. Provider business mailing address

2675 N DECATUR RD STE 200
DECATUR GA
30033-6132
US

V. Phone/Fax

Practice location:
  • Phone: 44-501-7040
  • Fax: 404-501-7644
Mailing address:
  • Phone: 404-778-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN238883
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN238883
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN238883
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: