Provider Demographics
NPI:1821065269
Name:CARMACK, KELLY A (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:CARMACK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:9326 MEDICAL PLAZA DR
Mailing Address - Street 2:STE B
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9138
Mailing Address - Country:US
Mailing Address - Phone:843-553-7070
Mailing Address - Fax:843-553-2223
Practice Address - Street 1:9326 MEDICAL PLAZA DR
Practice Address - Street 2:STE B
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9138
Practice Address - Country:US
Practice Address - Phone:843-553-7070
Practice Address - Fax:843-553-2223
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCAPN1504367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN1071Medicaid
SCQ32772Medicare UPIN