Provider Demographics
NPI:1760180988
Name:KENCADE-PICHON, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KENCADE-PICHON
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 1:955 MASTERS LN
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3579
Mailing Address - Country:US
Mailing Address - Phone:404-274-0526
Mailing Address - Fax:
Practice Address - Street 1:1700 MEDICAL WAY
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2195
Practice Address - Country:US
Practice Address - Phone:770-979-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-16
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6771227900000X
367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered