Basic Information
| Provider Information | |||||||||
| NPI: | 1467450643 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANCE | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 CLANCURRY PL | ||||||||
| Address2: | |||||||||
| City: | PAWLEYS ISLAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295856394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439790769 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 SINGLETON RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295269142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432345038 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 135833 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 8051506 | 05 | NC | MEDICAID |