Provider Demographics
NPI:1679377014
Name:ROSS, KELLIE M (MSN, APRN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:M
Last Name:ROSS
Suffix:
Gender:
Credentials:MSN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1086 LONDON ST STE B
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5761
Mailing Address - Country:US
Mailing Address - Phone:843-703-1027
Mailing Address - Fax:
Practice Address - Street 1:1086 LONDON ST STE B
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5761
Practice Address - Country:US
Practice Address - Phone:843-703-1027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-03
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30085363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health