Provider Demographics
NPI:1811418650
Name:KENNEDY, SOPHIA A (FNP)
Entity type:Individual
Prefix:MISS
First Name:SOPHIA
Middle Name:A
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5113 HOLLY SPRINGS PKWY
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-7440
Mailing Address - Country:US
Mailing Address - Phone:678-398-9697
Mailing Address - Fax:
Practice Address - Street 1:5113 HOLLY SPRINGS PKWY
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-7440
Practice Address - Country:US
Practice Address - Phone:783-989-6976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-02
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF1116598363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily