Provider Demographics
NPI:1629849302
Name:KENT, MADISON BLAIRE
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:BLAIRE
Last Name:KENT
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 1:4206 SEAVIEW ST APT 2
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-5142
Mailing Address - Country:US
Mailing Address - Phone:864-430-9948
Mailing Address - Fax:
Practice Address - Street 1:4520 BROAD ST
Practice Address - Street 2:
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569-2422
Practice Address - Country:US
Practice Address - Phone:843-756-0959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28278363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily