Provider Demographics
NPI:1548719073
Name:KENNEY, ELLEN (PA)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:KENNEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:BOBICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2220 N DRUID HILLS RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2220 N DRUID HILLS RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-3117
Practice Address - Country:US
Practice Address - Phone:925-788-1011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD005118133V00000X
GA11834363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered