Provider Demographics
NPI:1477717551
Name:KELLY, NANETTE C (FNP-C)
Entity Type:Individual
Prefix:
First Name:NANETTE
Middle Name:C
Last Name:KELLY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8121 ROURK ST
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4128
Mailing Address - Country:US
Mailing Address - Phone:843-692-5000
Mailing Address - Fax:843-692-5010
Practice Address - Street 1:817 FARRAR DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8747
Practice Address - Country:US
Practice Address - Phone:843-234-1660
Practice Address - Fax:843-234-1661
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17929363LF0000X
MDR088240363LG0600X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology