Provider Demographics
NPI:1265228795
Name:DITTMAR, KENZIE (PA)
Entity type:Individual
Prefix:
First Name:KENZIE
Middle Name:
Last Name:DITTMAR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KENZIE
Other - Middle Name:PIERCE
Other - Last Name:DITTMAR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:1502 N AMANDA CIR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 SAM PERRY BLVD STE 121
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4465
Practice Address - Country:US
Practice Address - Phone:540-899-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-21
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant