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General NPI Number Information
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NPI Number | 1740600048
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Entity Type | Individual
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Provider Name | KENYATTA MIREKU MD
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Gender | Female
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Dates
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Enumeration Date | 04/24/2014
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Last Update Date | 10/02/2018
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Provider Practice Location Address
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Address Line | 771 OLD NORCROSS RD STE 260
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-4981
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Country | US
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Telephone | 770-962-5040
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Fax | 770-962-5056
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Provider Business Mailing Address
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Address Line | 151 SOUTHHALL LN STE 300
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City | MAITLAND
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State | FL
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Zip | 32751-7172
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 080834
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License Number State | GA
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