Provider Demographics
NPI:1427036409
Name:MCCOLLUM, KENNON HOWARD (MSN)
Entity Type:Individual
Prefix:MR
First Name:KENNON
Middle Name:HOWARD
Last Name:MCCOLLUM
Suffix:
Gender:M
Credentials:MSN
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Other - Credentials:
Mailing Address - Street 1:1835 SAVOY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1072
Mailing Address - Country:US
Mailing Address - Phone:678-289-0549
Mailing Address - Fax:678-289-8756
Practice Address - Street 1:1045 SOUTHCREST DR
Practice Address - Street 2:SUITE 200
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6113
Practice Address - Country:US
Practice Address - Phone:678-289-0549
Practice Address - Fax:678-289-8756
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2020-08-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GARN102128363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000968745JMedicaid
GA000968745KMedicaid
GA000968745HMedicaid
GA20250I1501Medicare PIN
GAP84308Medicare UPIN