Provider Demographics
NPI:1215980081
Name:KENNON, WENDY HAWKINS (AA)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:HAWKINS
Last Name:KENNON
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 BURNT HICKORY WAY
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-4468
Mailing Address - Country:US
Mailing Address - Phone:706-494-7075
Mailing Address - Fax:
Practice Address - Street 1:616 19TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1528
Practice Address - Country:US
Practice Address - Phone:706-494-4262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002991367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA32BBBPQMedicare PIN
GAS44153Medicare UPIN