Provider Demographics
NPI:1992076467
Name:NETTLES, KENNA HOGUE (PA-C, ATC)
Entity type:Individual
Prefix:
First Name:KENNA
Middle Name:HOGUE
Last Name:NETTLES
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:KENNA
Other - Middle Name:LAINE
Other - Last Name:HOGUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:3719 DAUPHIN ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-1753
Mailing Address - Country:US
Mailing Address - Phone:251-460-5333
Mailing Address - Fax:251-460-5295
Practice Address - Street 1:3719 DAUPHIN ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-1753
Practice Address - Country:US
Practice Address - Phone:251-460-5333
Practice Address - Fax:251-460-5295
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-16
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA788363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant