Provider Demographics
NPI:1861855645
Name:NIERMEIER, KELLY K (CPNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:K
Last Name:NIERMEIER
Suffix:
Gender:F
Credentials:CPNP
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 3788
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29230-3788
Mailing Address - Country:US
Mailing Address - Phone:803-733-5969
Mailing Address - Fax:803-753-5591
Practice Address - Street 1:500 N 12TH ST
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-6502
Practice Address - Country:US
Practice Address - Phone:803-217-0415
Practice Address - Fax:803-939-1650
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173395363LP0200X
SC21241363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC21241Medicaid
SCNP4742Medicaid