Provider Demographics
NPI:1285701490
Name:WRIGHT, KENNETHA DELORES (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETHA
Middle Name:DELORES
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KENNETHA
Other - Middle Name:DELORES
Other - Last Name:MANNING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:6271 BRANCH BROOK WAY
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-6086
Mailing Address - Country:US
Mailing Address - Phone:770-498-8564
Mailing Address - Fax:
Practice Address - Street 1:2070 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5306
Practice Address - Country:US
Practice Address - Phone:404-636-6680
Practice Address - Fax:404-636-1618
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1541152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU67681Medicare UPIN
GA41ZCFXLMedicare ID - Type Unspecified