Provider Demographics
NPI:1558328351
Name:KELLY, JENNIFER AMY
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:AMY
Last Name:KELLY
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 1:293 GREYSTONE BLVD
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-8004
Mailing Address - Country:US
Mailing Address - Phone:803-296-2548
Mailing Address - Fax:803-296-2548
Practice Address - Street 1:5 MEDICAL PARK
Practice Address - Street 2:PALMETTO HEALTH RICHLAND
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-296-2548
Practice Address - Fax:803-296-2548
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2631367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN1434Medicaid
SCAN1434Medicaid
SCQ33984Medicare PIN