Provider Demographics
NPI:1477995470
Name:KERNODLE, JUSTIN NICOLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JUSTIN
Middle Name:NICOLE
Last Name:KERNODLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:JUSTIN
Other - Middle Name:NICOLE
Other - Last Name:KERNODLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 602645
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2645
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2454
Practice Address - Street 1:2095 HENRY TECKLENBURG DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5733
Practice Address - Country:US
Practice Address - Phone:843-402-1037
Practice Address - Fax:843-402-1295
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL1941363AM0700X
SC1941363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2123PAMedicaid