Provider Demographics
NPI:1093489817
Name:CASSEDY, KEVIN
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:CASSEDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4151 OLD LINCOLNTON RD
Mailing Address - Street 2:
Mailing Address - City:APPLING
Mailing Address - State:GA
Mailing Address - Zip Code:30802-4116
Mailing Address - Country:US
Mailing Address - Phone:706-294-6545
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-294-6545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN147826163WN0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN0800XNursing Service ProvidersRegistered NurseNeuroscience
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN147826Medicaid