Provider Demographics
NPI:1063951408
Name:KENNEDY-HOWELL, PHYLLIS A (FNP-BC)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:A
Last Name:KENNEDY-HOWELL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 GORNTO CEMETERY RD
Mailing Address - Street 2:
Mailing Address - City:BARNEY
Mailing Address - State:GA
Mailing Address - Zip Code:31625-3248
Mailing Address - Country:US
Mailing Address - Phone:229-456-2152
Mailing Address - Fax:
Practice Address - Street 1:2700 N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1772
Practice Address - Country:US
Practice Address - Phone:229-249-8687
Practice Address - Fax:229-249-9282
Is Sole Proprietor?:No
Enumeration Date:2017-02-17
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN189066363LP0808X
GA189066363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily