Healthcare Provider Details

I. General information

NPI: 1063190585
Provider Name (Legal Business Name): KENDALL ELIZABETH TOWE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 RIVERSIDE PKWY STE 100
LAWRENCEVILLE GA
30043-5926
US

IV. Provider business mailing address

4580 BARONY DR
SUWANEE GA
30024-6949
US

V. Phone/Fax

Practice location:
  • Phone: 678-535-0067
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number11722
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number11722
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: