Provider Demographics
NPI:1790260453
Name:MATTINGLY KELLEY, MORGAN
Entity type:Individual
Prefix:
First Name:MORGAN
Middle Name:
Last Name:MATTINGLY KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 GASPARILLA CIR
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-4814
Mailing Address - Country:US
Mailing Address - Phone:843-340-8050
Mailing Address - Fax:
Practice Address - Street 1:3001 NEWCASTLE LOOP
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-4502
Practice Address - Country:US
Practice Address - Phone:843-887-7546
Practice Address - Fax:854-588-6246
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22203363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily