Provider Demographics
NPI:1508244385
Name:ATWELL, KENISHA DANIA (MD)
Entity Type:Individual
Prefix:MS
First Name:KENISHA
Middle Name:DANIA
Last Name:ATWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 COUNTY ROAD 111 BLDG D
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-3383
Mailing Address - Country:US
Mailing Address - Phone:631-727-5065
Mailing Address - Fax:
Practice Address - Street 1:496 COUNTY ROAD 111 BLDG D
Practice Address - Street 2:
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949-3383
Practice Address - Country:US
Practice Address - Phone:631-727-5065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY325472208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program