Provider Demographics
NPI:1699832147
Name:KENT, MARY ALICE (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:KENT
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 1:170 AMENDMENT AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-3073
Mailing Address - Country:US
Mailing Address - Phone:803-324-7607
Mailing Address - Fax:860-233-5212
Practice Address - Street 1:170 AMENDMENT AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3073
Practice Address - Country:US
Practice Address - Phone:803-324-7607
Practice Address - Fax:803-324-4097
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2289363AM0700X
CT001239363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001239OtherMEDICAL LICENSE