Basic Information
| Provider Information | |||||||||
| NPI: | 1649388513 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2051 CHARLIE HALL BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435732535 | ||||||||
| FaxNumber: | 8435732534 | ||||||||
| Practice Location | |||||||||
| Address1: | 1952 LONG GROVE DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439712992 | ||||||||
| FaxNumber: | 8439712998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 08/19/2013 | ||||||||
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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 | 363L00000X | 1877 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | NP0692 | 05 | SC | MEDICAID |