Provider Demographics
NPI:1295843167
Name:ROMERO, KELLY I (NNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:I
Last Name:ROMERO
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:I
Other - Last Name:ROSCOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NNP
Mailing Address - Street 1:PO BOX 751461
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1461
Mailing Address - Country:US
Mailing Address - Phone:843-792-1414
Mailing Address - Fax:
Practice Address - Street 1:171 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-0001
Practice Address - Country:US
Practice Address - Phone:843-792-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2646363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0912Medicaid
SCAA1062Medicare ID - Type Unspecified
SCNP0912Medicaid