Provider Demographics
NPI:1275728487
Name:MERRELL, KELLY LYNN (ANP-BC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:MERRELL
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12810
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4019
Mailing Address - Country:US
Mailing Address - Phone:843-797-5050
Mailing Address - Fax:843-797-3633
Practice Address - Street 1:2880 TRICOM ST
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9171
Practice Address - Country:US
Practice Address - Phone:843-797-5050
Practice Address - Fax:843-797-3633
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3320363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1902246077OtherARCIS HEALTHCARE GROUP NPI
SC46-2535418OtherARCIS HEALTHCARE GROUP TIN
SCD043OtherGROUP MEDICARE PTAN
SCNP1509Medicaid