Provider Demographics
NPI:1710982772
Name:GOSNELL, KIM (NP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:GOSNELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6308
Mailing Address - Fax:
Practice Address - Street 1:107 OMNI DR STE A
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-9448
Practice Address - Country:US
Practice Address - Phone:864-885-7886
Practice Address - Fax:864-885-7890
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0247Medicaid
SCNP0247Medicaid
SC6526Medicare ID - Type Unspecified