Provider Demographics
NPI:1851716708
Name:ALTOBELLO, KENNA COURTNEY STEPHANIE (APN)
Entity Type:Individual
Prefix:
First Name:KENNA
Middle Name:COURTNEY STEPHANIE
Last Name:ALTOBELLO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:104 SALUDA POINTE DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7295
Practice Address - Country:US
Practice Address - Phone:803-296-7846
Practice Address - Fax:803-296-9699
Is Sole Proprietor?:No
Enumeration Date:2014-03-03
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041323580163W00000X
SC18805364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP4873Medicaid