Provider Demographics
NPI:1346056678
Name:JOSEPH, KENNY
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7106 IVY CHASE WAY NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-4253
Mailing Address - Country:US
Mailing Address - Phone:313-200-4543
Mailing Address - Fax:
Practice Address - Street 1:7106 IVY CHASE WAY NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4253
Practice Address - Country:US
Practice Address - Phone:313-200-4543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No171R00000XOther Service ProvidersInterpreter
No172A00000XOther Service ProvidersDriver