Provider Demographics
NPI:1336780147
Name:CANADY, KRISTEN LEEANN (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LEEANN
Last Name:CANADY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5864 N RHETT AVE APT 5B
Mailing Address - Street 2:
Mailing Address - City:HANAHAN
Mailing Address - State:SC
Mailing Address - Zip Code:29410-2531
Mailing Address - Country:US
Mailing Address - Phone:252-558-3232
Mailing Address - Fax:
Practice Address - Street 1:610 OCEAN HWY W
Practice Address - Street 2:
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4048
Practice Address - Country:US
Practice Address - Phone:910-356-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09492363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty