Basic Information
Provider Information | |||||||||
NPI: | 1730587262 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEEDLY | ||||||||
FirstName: | KELSEY | ||||||||
MiddleName: | N | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NASH | ||||||||
OtherFirstName: | KELSEY | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 201 SIGMA DR | ||||||||
Address2: | STE 100 | ||||||||
City: | SUMMERVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 294867715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8435727727 | ||||||||
FaxNumber: | 8435695895 | ||||||||
Practice Location | |||||||||
Address1: | 7 S ALLIANCE DR STE 202A | ||||||||
Address2: |   | ||||||||
City: | GOOSE CREEK | ||||||||
State: | SC | ||||||||
PostalCode: | 294457269 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8433760670 | ||||||||
FaxNumber: | 8433760669 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/16/2014 | ||||||||
LastUpdateDate: | 08/30/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2229 | SC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 2056PA | 05 | SC |   | MEDICAID |