Provider Demographics
NPI:1821850447
Name:ELLIS, KELLY (APRN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 RIVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-2901
Mailing Address - Country:US
Mailing Address - Phone:843-761-8000
Mailing Address - Fax:843-761-4136
Practice Address - Street 1:1 RIVERWOOD DR
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-2901
Practice Address - Country:US
Practice Address - Phone:843-761-8000
Practice Address - Fax:843-761-8000
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCAPN28247RX363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health