Provider Demographics
NPI:1609184316
Name:KITTLE, KYM L (PA)
Entity Type:Individual
Prefix:MS
First Name:KYM
Middle Name:L
Last Name:KITTLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2229 MAGNOLIA MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7562
Mailing Address - Country:US
Mailing Address - Phone:843-224-2488
Mailing Address - Fax:
Practice Address - Street 1:161 ASHLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8905
Practice Address - Country:US
Practice Address - Phone:843-224-2488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA800363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical