BOEGGEMAN, KELLIE L (ARNP)

Provider Demographics

• NPI: 1669662086
• Name: BOEGGEMAN, KELLIE L (ARNP)
• Entity Type: Individual
• First Name: KELLIE
• Middle Name: L
• Last Name: BOEGGEMAN
• Gender: F
• Credentials: ARNP
• Mailing Address - Street 1: 1 WELLNESS BLVD
• Mailing Address - Street 2: STE 106
• Mailing Address - City: IRMO
• Mailing Address - State: SC
• Mailing Address - Zip Code: 29063-2872
• Mailing Address - Country: US
• Mailing Address - Phone: 803-888-2282
• Mailing Address - Fax: 803-888-2299
• Practice Address - Street 1: 1 WELLNESS BLVD STE 106
• Practice Address - City: IRMO
• Practice Address - State: SC
• Practice Address - Zip Code: 29063-2872
• Practice Address - Country: US
• Practice Address - Phone: 803-888-2282
• Practice Address - Fax: 803-888-2299
• Is Sole Proprietor?: No
• Enumeration Date: 2007-08-01
• Last Update Date: 2021-02-23

Provider Licenses

State	License ID	Taxonomies
NC	248427	363L00000X
FL	9165739	363LF0000X
SC	APN355	363L00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner
No	363LF0000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Family

Provider Identifiers

State	Identifier ID	ID Type	Issuer
NC	7006413	Medicaid
SC	NP1310	Medicaid
NC	NC8573E	Medicare PIN
NC	NC8573I	Medicare PIN
NC	NC8573K	Medicare PIN
NC	NC8573C	Medicare PIN
NC	NC8573D	Medicare PIN
NC	NC8573N	Medicare PIN
NC	NC8573B	Medicare PIN
NC	NC8573A	Medicare PIN
NC	NC8573F	Medicare PIN
NC	NC8573G	Medicare PIN
NC	NC8573J	Medicare PIN
NC	NC8573P	Medicare PIN
SC	AA32577772	Medicare PIN
SC	NP1310	Medicaid
NC	NC8573M	Medicare PIN