Healthcare Provider Details

I. General information

NPI: 1215392964
Provider Name (Legal Business Name): KWANZA WASHINGTON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2015
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2782 N COBB PKWY
KENNESAW GA
30152-3472
US

IV. Provider business mailing address

2782 N COBB PKWY
KENNESAW GA
30152-3472
US

V. Phone/Fax

Practice location:
  • Phone: 706-329-1329
  • Fax:
Mailing address:
  • Phone: 434-929-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024179542
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP224319
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number76506
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP224319
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: