Provider Demographics
NPI:1811479207
Name:KENYAN, GEORGIA LYNN (MA)
Entity type:Individual
Prefix:MRS
First Name:GEORGIA
Middle Name:LYNN
Last Name:KENYAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5180 LINTON CUTOFF RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-8770
Mailing Address - Country:US
Mailing Address - Phone:318-617-5953
Mailing Address - Fax:
Practice Address - Street 1:458 HERNDON ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4859
Practice Address - Country:US
Practice Address - Phone:318-429-6938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1417252230Medicaid