Basic Information
| Provider Information | |||||||||
| NPI: | 1649746025 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 SEAPORT LN UNIT 1325 | ||||||||
| Address2: | |||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294642731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433279466 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9221 UNIVERSITY BLVD STE 102 | ||||||||
| Address2: | |||||||||
| City: | NORTH CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435760700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2018 | ||||||||
| LastUpdateDate: | 10/23/2018 | ||||||||
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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 | MPA.3061 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.