Provider Demographics
NPI:1770513103
Name:MOCK, KATHRYN S (FNP)
Entity type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:S
Last Name:MOCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15 MEDICAL PARK RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203
Mailing Address - Country:US
Mailing Address - Phone:803-255-3417
Mailing Address - Fax:803-255-3451
Practice Address - Street 1:8301 FARROW RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-3245
Practice Address - Country:US
Practice Address - Phone:803-255-3417
Practice Address - Fax:803-255-3451
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC2154363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0964Medicaid