Healthcare Provider Details

I. General information

NPI: 1508244385
Provider Name (Legal Business Name): KENISHA DANIA ATWELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2015
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 HARRISON ST STE 455
JOHNSON CITY NY
13790-2176
US

IV. Provider business mailing address

496 COUNTY ROAD 111 BLDG D
MANORVILLE NY
11949-3383
US

V. Phone/Fax

Practice location:
  • Phone: 607-763-8100
  • Fax:
Mailing address:
  • Phone: 631-727-5065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number325472
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number325472
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: