Provider Demographics
NPI:1013303650
Name:PROVIDENCE, KAYNESSA CELENA (MD)
Entity type:Individual
Prefix:DR
First Name:KAYNESSA
Middle Name:CELENA
Last Name:PROVIDENCE
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 1:54 TOWER RD NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-6977
Mailing Address - Country:US
Mailing Address - Phone:770-427-4682
Mailing Address - Fax:770-499-8562
Practice Address - Street 1:54 TOWER RD NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-6977
Practice Address - Country:US
Practice Address - Phone:770-427-4682
Practice Address - Fax:770-499-8562
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-10
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86204207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine