Provider Demographics
NPI:1417304734
Name:ARDIS, KELLY (AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ARDIS
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 ANDREWS AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-2107
Mailing Address - Country:US
Mailing Address - Phone:864-992-2875
Mailing Address - Fax:
Practice Address - Street 1:216 ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-2107
Practice Address - Country:US
Practice Address - Phone:864-992-2875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-17
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20183363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health