Provider Demographics
NPI:1124504782
Name:WADDELL, KENNETH WAYNE JR (NP)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:WADDELL
Suffix:JR
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 N LEE ST STE A
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:GA
Mailing Address - Zip Code:31029-2122
Mailing Address - Country:US
Mailing Address - Phone:478-994-0437
Mailing Address - Fax:
Practice Address - Street 1:120 N LEE ST STE A
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:GA
Practice Address - Zip Code:31029
Practice Address - Country:US
Practice Address - Phone:478-994-0437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN249530363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner