Healthcare Provider Details

I. General information

NPI: 1053572537
Provider Name (Legal Business Name): AMANTIA KENNEDY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3024 NEW BERN AVE
RALEIGH NC
27610-1247
US

IV. Provider business mailing address

2920 HIGHWOODS BLVD
RALEIGH NC
27604-0010
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-7844
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number148783
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2012-01056
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: