Basic Information
| Provider Information | |||||||||
| NPI: | 1063096154 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KUETE | ||||||||
| FirstName: | NELSON KEVIN | ||||||||
| MiddleName: | TANEFO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KUETE | ||||||||
| OtherFirstName: | NELSON | ||||||||
| OtherMiddleName: | KEVIN TANEFO | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6911 SLATE STONE WAY SE | ||||||||
| Address2: | |||||||||
| City: | MABLETON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301265425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708279756 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1365 CLIFTON RD NE STE B1400 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047784898 | ||||||||
| FaxNumber: | 4047784006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2021 | ||||||||
| LastUpdateDate: | 05/06/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.