Provider Demographics
NPI:1972030765
Name:KENNAH, PAOLA JETZABELLA (PA-C)
Entity Type:Individual
Prefix:
First Name:PAOLA
Middle Name:JETZABELLA
Last Name:KENNAH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23343 NW COUNTY ROAD 236
Mailing Address - Street 2:
Mailing Address - City:HIGH SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32643-9669
Mailing Address - Country:US
Mailing Address - Phone:386-454-0698
Mailing Address - Fax:
Practice Address - Street 1:2349 VILLAGE SQUARE PKWY STE 110-111
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-6355
Practice Address - Country:US
Practice Address - Phone:904-385-2023
Practice Address - Fax:904-385-2454
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9117136363AM0700X, 363A00000X
AK139211363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical