Provider Demographics
NPI:1649388513
Name:KELLEY, KATHLEEN M (PNP)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:M
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2051 CHARLIE HALL BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414
Mailing Address - Country:US
Mailing Address - Phone:843-573-2535
Mailing Address - Fax:843-573-2534
Practice Address - Street 1:1952 LONG GROVE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464
Practice Address - Country:US
Practice Address - Phone:843-971-2992
Practice Address - Fax:843-971-2998
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1877363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0692Medicaid
SCNP0692Medicaid
P91161Medicare UPIN