Provider Demographics
NPI:1902623259
Name:WILSON, KENDRAH DAWANNA
Entity type:Individual
Prefix:
First Name:KENDRAH
Middle Name:DAWANNA
Last Name:WILSON
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 1:704 WHEELER ST APT SUITE
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-8315
Mailing Address - Country:US
Mailing Address - Phone:912-540-0323
Mailing Address - Fax:
Practice Address - Street 1:1709 OSBORNE RD APT SUITE
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-9141
Practice Address - Country:US
Practice Address - Phone:912-540-0323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA105415225700000X
GAMT015102225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist