MEDICARE: KENNEDY LYNN DAVIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	LD007940	GA

General Provider Information

NPI Number	:	1306709035
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNEDY LYNN DAVIS

Provider Business Mailing Address
First Line	:	422 GUM CREEK AIRPORT RD
Second Line	:
City	:	ROOPVILLE
State	:	GA
Zip	:	30170-3708
Country	:	US
Telephone Number	:	404-984-9019
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 CELEBRATE LIFE PKWY
Second Line	:
City	:	NEWNAN
State	:	GA
Zip	:	30265-8001
Country	:	US
Telephone Number	:	770-400-6410
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2025
Last Update Date	:	12/09/2025

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