Provider Demographics
NPI:1013148626
Name:KENNEDY, SHEILA (MD)
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2491 PANOLA RD
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-4831
Mailing Address - Country:US
Mailing Address - Phone:678-205-4999
Mailing Address - Fax:678-205-4969
Practice Address - Street 1:1430 FIVE FORKS TRICKUM RD ST 220
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-8182
Practice Address - Country:US
Practice Address - Phone:678-578-4983
Practice Address - Fax:678-578-4988
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA68227207Q00000X
NJ390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003140093BMedicaid
GA003140093AMedicaid