Provider Demographics
NPI:1538143391
Name:BOONE, KATHLEEN A (FNP)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:A
Last Name:BOONE
Suffix:
Gender:F
Credentials:FNP
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 421718
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-4203
Mailing Address - Country:US
Mailing Address - Phone:843-652-8226
Mailing Address - Fax:
Practice Address - Street 1:9699 OCEAN HWY
Practice Address - Street 2:WACCMAAW MEDICAL CENTER
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-7425
Practice Address - Country:US
Practice Address - Phone:843-237-4296
Practice Address - Fax:843-237-0495
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCF1372363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1370Medicaid
SCP173655076Medicare ID - Type Unspecified
P17365Medicare UPIN