Provider Demographics
NPI:1457817785
Name:YOUNG, KOMALEATHER
Entity Type:Individual
Prefix:
First Name:KOMALEATHER
Middle Name:
Last Name:YOUNG
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 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7303
Mailing Address - Fax:
Practice Address - Street 1:1 RICHLAND MEDICAL PARK DR STE 420
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6833
Practice Address - Country:US
Practice Address - Phone:803-545-5350
Practice Address - Fax:803-545-5352
Is Sole Proprietor?:No
Enumeration Date:2019-02-12
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22460363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP5771Medicaid