Provider Demographics
NPI:1598264723
Name:GRAY, KENNEDY BRIANA-MARIE
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:BRIANA-MARIE
Last Name:GRAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:998 BETHSAIDA RD
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-2237
Mailing Address - Country:US
Mailing Address - Phone:770-997-8376
Mailing Address - Fax:
Practice Address - Street 1:998 BETHSAIDA RD
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-2237
Practice Address - Country:US
Practice Address - Phone:770-997-8376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer