Provider Demographics
NPI:1194222539
Name:KELLEY, GWENDELL MCDANIEL (APRN)
Entity Type:Individual
Prefix:MRS
First Name:GWENDELL
Middle Name:MCDANIEL
Last Name:KELLEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BROWNING RD
Mailing Address - Street 2:
Mailing Address - City:CENTRAL
Mailing Address - State:SC
Mailing Address - Zip Code:29630-9440
Mailing Address - Country:US
Mailing Address - Phone:864-650-7475
Mailing Address - Fax:
Practice Address - Street 1:3424 CLEMSON BLVD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621
Practice Address - Country:US
Practice Address - Phone:864-261-3022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22120363LF0000X
SC86088207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine