Provider Demographics
NPI:1578988432
Name:BRANSTETTER, KELLY CANADA (CPNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:CANADA
Last Name:BRANSTETTER
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ELIZABETH
Other - Last Name:CANADA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:14 RICHLAND MEDICAL PARK DR STE 310
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6883
Practice Address - Country:US
Practice Address - Phone:803-434-8450
Practice Address - Fax:803-758-0137
Is Sole Proprietor?:No
Enumeration Date:2014-02-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18707363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP3240Medicaid
SCNP3240Medicaid