Provider Demographics
NPI:1790415289
Name:MADDOX, KENNISHA AVONTIA
Entity Type:Individual
Prefix:
First Name:KENNISHA
Middle Name:AVONTIA
Last Name:MADDOX
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 1:3201 WEEPING WILLOW CT APT 24
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-2569
Mailing Address - Country:US
Mailing Address - Phone:240-455-8054
Mailing Address - Fax:
Practice Address - Street 1:2656 BOWEN RD SE APT 202
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-6612
Practice Address - Country:US
Practice Address - Phone:202-718-6501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant