Provider Demographics
NPI:1326048349
Name:KAYSE, MARY W (PNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:W
Last Name:KAYSE
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 MONTICELLO RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-4156
Mailing Address - Country:US
Mailing Address - Phone:803-252-7001
Mailing Address - Fax:803-252-5219
Practice Address - Street 1:4605 MONTICELLO RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-4156
Practice Address - Country:US
Practice Address - Phone:803-252-7001
Practice Address - Fax:803-252-5219
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN1242363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1795Medicaid
SCAPN1242OtherSTATE LICENCE NUMBER