Provider Demographics
NPI:1245754456
Name:MYNATT, KENNETH (PT)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:MYNATT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1459 MONTREAL RD STE 304
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-6920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1459 MONTREAL RD STE 304
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-6920
Practice Address - Country:US
Practice Address - Phone:404-251-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-29
Last Update Date:2017-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013026208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation