Provider Demographics
NPI:1760804256
Name:KELLEY, SARETTE J (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SARETTE
Middle Name:J
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SARETTE
Other - Middle Name:N
Other - Last Name:JENDERNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:180 WINGO WAY
Practice Address - Street 2:SUITE 207
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-1810
Practice Address - Country:US
Practice Address - Phone:843-884-5101
Practice Address - Fax:843-849-7726
Is Sole Proprietor?:No
Enumeration Date:2014-01-17
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2056363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1842PAMedicaid