Provider Demographics
NPI:1194417394
Name:KENEBREW, KIA DANDRIELLE
Entity type:Individual
Prefix:
First Name:KIA
Middle Name:DANDRIELLE
Last Name:KENEBREW
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 1:451 LEE ST SW APT 4050B
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-1408
Mailing Address - Country:US
Mailing Address - Phone:281-236-4637
Mailing Address - Fax:
Practice Address - Street 1:451 LEE ST SW APT 4050B
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-1408
Practice Address - Country:US
Practice Address - Phone:281-236-4637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer