Individual
KENNEDY FAYRENE WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
720 WESTVIEW DR SW, ATLANTA, GA 30310-1458
(404) 756-1959
Mailing address
17703 LAGUNA TRAIL DR, HOUSTON, TX 77095-7163
(281) 978-1429
Taxonomy
Speciality
Code
Description
License number
State
390200000X
Student in an Organized Health Care Education/Training Program
Primary
—
—
Other
Enumeration date
06/11/2025
Last updated
06/11/2025
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