Provider Demographics
NPI:1821344847
Name:KENNEDY, ERICA MARIE (NP)
Entity Type:Individual
Prefix:MS
First Name:ERICA
Middle Name:MARIE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:MARIE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25 SAINT CHARLES PL
Mailing Address - Street 2:
Mailing Address - City:SHARPSBURG
Mailing Address - State:GA
Mailing Address - Zip Code:30277-6933
Mailing Address - Country:US
Mailing Address - Phone:678-708-4300
Mailing Address - Fax:678-708-4301
Practice Address - Street 1:4000 SHAKERAG HILL
Practice Address - Street 2:STE 204
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-4047
Practice Address - Country:US
Practice Address - Phone:678-578-7636
Practice Address - Fax:678-216-1885
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN176824363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner