Provider Demographics
NPI:1518278829
Name:CONNELL, CYMANTHIA KEESHA (MD)
Entity Type:Individual
Prefix:
First Name:CYMANTHIA
Middle Name:KEESHA
Last Name:CONNELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CYMANTHIA
Other - Middle Name:KEESHA
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 742495
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2495
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:81 NORTHSIDE DAWSON DR STE 100A
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-7166
Practice Address - Country:US
Practice Address - Phone:706-216-6000
Practice Address - Fax:706-216-6010
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-01
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA68859207Q00000X
KS0440473207Q00000X
MO207Q00000X261QP2300X
MO2013022689207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1870009OtherMEDICARE PTAN