Provider Demographics
NPI:1619459849
Name:REQUA, KELSIE CHANDLER (PA)
Entity Type:Individual
Prefix:
First Name:KELSIE
Middle Name:CHANDLER
Last Name:REQUA
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 1:304 ALWYN BLVD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-4000
Mailing Address - Country:US
Mailing Address - Phone:843-412-2053
Mailing Address - Fax:
Practice Address - Street 1:2863 N HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-8962
Practice Address - Country:US
Practice Address - Phone:843-572-5990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant