Provider Demographics
NPI:1376995159
Name:KELLETT, NATALIE NICOLE
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:NICOLE
Last Name:KELLETT
Suffix:
Gender:F
Credentials:
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 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:120 HEYWOOD AVENUE SUITE 200
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302
Practice Address - Country:US
Practice Address - Phone:864-573-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20315363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC88066084OtherMEDICARE PIN
SCSCA009J577OtherMEDICARE PIN
SCSC88064722OtherMEDICARE PTAN
SCNP3964Medicaid
SCSC88066067OtherMEDICARE PTAN
SCSC88066121OtherMEDICARE PTAN