Provider Demographics
NPI:1508882184
Name:KILGORE, COLLEEN MARCIA (FNP APRN BC)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:MARCIA
Last Name:KILGORE
Suffix:
Gender:F
Credentials:FNP APRN BC
Other - Prefix:MS
Other - First Name:COLLEEN
Other - Middle Name:MARCIA
Other - Last Name:BROWNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1620 BROUGHTON STREET
Mailing Address - Street 2:P.O. BOX 2549
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116
Mailing Address - Country:US
Mailing Address - Phone:803-531-6030
Mailing Address - Fax:803-531-6056
Practice Address - Street 1:1620 BROUGHTON ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4867
Practice Address - Country:US
Practice Address - Phone:803-531-6030
Practice Address - Fax:803-531-6056
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC616363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCF75463Medicaid