Provider Demographics
NPI:1457135063
Name:KENNEDY, MARQUIS
Entity Type:Individual
Prefix:
First Name:MARQUIS
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:488 LINBERGH AVE
Mailing Address - Street 2:APARTMENT
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324
Mailing Address - Country:US
Mailing Address - Phone:424-356-7575
Mailing Address - Fax:
Practice Address - Street 1:488 LINBERGH AVE
Practice Address - Street 2:APARTMENT
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324
Practice Address - Country:US
Practice Address - Phone:424-356-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant