Provider Demographics
NPI:1720548704
Name:KENWAY, PAIGE B (AGPCNP-BC)
Entity Type:Individual
Prefix:MS
First Name:PAIGE
Middle Name:B
Last Name:KENWAY
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:MISS
Other - First Name:PAIGE
Other - Middle Name:D
Other - Last Name:BURKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1835 SAVOY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341-1071
Mailing Address - Country:US
Mailing Address - Phone:678-817-1117
Mailing Address - Fax:678-817-0823
Practice Address - Street 1:132 OLD NORTON RD STE 200
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-4873
Practice Address - Country:US
Practice Address - Phone:678-817-1117
Practice Address - Fax:678-817-0823
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN222344363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003217336AMedicaid
GAG11383AOtherMEDICARE PTAN