Provider Demographics
NPI:1912752452
Name:KENNEBREW, BRYASHA
Entity Type:Individual
Prefix:
First Name:BRYASHA
Middle Name:
Last Name:KENNEBREW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3649 SURREY LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-2747
Mailing Address - Country:US
Mailing Address - Phone:706-750-5742
Mailing Address - Fax:
Practice Address - Street 1:2312 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-2513
Practice Address - Country:US
Practice Address - Phone:706-750-5742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA23252679251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health