Provider Demographics
NPI:1417579269
Name:CLINKENBEARD, KACY
Entity Type:Individual
Prefix:
First Name:KACY
Middle Name:
Last Name:CLINKENBEARD
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 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:843-792-6200
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:29425-8908
Practice Address - Country:US
Practice Address - Phone:843-792-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-15
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC962363A00000X, 363AM0700X, 363AS0400X
SC4063363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical