Basic Information
| Provider Information | |||||||||
| NPI: | 1477134880 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODE | ||||||||
| FirstName: | KENNEDY | ||||||||
| MiddleName: | PAIGE | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 OLD TROLLEY RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | SUMMERVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294855294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433762670 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1101 OLD TROLLEY RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | SUMMERVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294855294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433762670 | ||||||||
| FaxNumber: | 8433762790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2021 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 24894 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 24894 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | NP8512 | 05 | SC | MEDICAID |