Provider Demographics
NPI:1770090896
Name:KITTRELL, BRETTA COOK (FNP)
Entity type:Individual
Prefix:
First Name:BRETTA
Middle Name:COOK
Last Name:KITTRELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:BAMBERG
Mailing Address - State:SC
Mailing Address - Zip Code:29003-1318
Mailing Address - Country:US
Mailing Address - Phone:803-245-5168
Mailing Address - Fax:803-245-6275
Practice Address - Street 1:450 NORTH ST
Practice Address - Street 2:
Practice Address - City:BAMBERG
Practice Address - State:SC
Practice Address - Zip Code:29003-1318
Practice Address - Country:US
Practice Address - Phone:803-245-5168
Practice Address - Fax:803-245-6275
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21571363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner