Provider Demographics
NPI:1821363094
Name:VERNON, KELLIE P (LMBT SC#4771)
Entity Type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:P
Last Name:VERNON
Suffix:
Gender:F
Credentials:LMBT SC#4771
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 959
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:SC
Mailing Address - Zip Code:29661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:275 WILDAZALEA LANE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:SC
Practice Address - Zip Code:29661
Practice Address - Country:US
Practice Address - Phone:864-270-0205
Practice Address - Fax:864-836-8101
Is Sole Proprietor?:No
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4771225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist