Basic Information
| Provider Information | |||||||||
| NPI: | 1821064395 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENDRICK | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | H. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2041 MESA VALLEY WAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301068157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709441100 | ||||||||
| FaxNumber: | 7709446469 | ||||||||
| Practice Location | |||||||||
| Address1: | 2041 MESA VALLEY WAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301068157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709441100 | ||||||||
| FaxNumber: | 7709446469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 02/05/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 004549 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 407818938A | 05 | GA | MEDICAID | 407818938C | 05 | GA | MEDICAID | 407818938D | 05 | GA | MEDICAID |