Provider Demographics
NPI:1811156938
Name:PRICE, KATHLEEN O (APRN)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:O
Last Name:PRICE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 S GOOSE CREEK BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-3136
Mailing Address - Country:US
Mailing Address - Phone:843-553-2211
Mailing Address - Fax:843-553-2210
Practice Address - Street 1:122 S GOOSE CREEK BLVD STE B
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-3136
Practice Address - Country:US
Practice Address - Phone:843-553-2211
Practice Address - Fax:843-553-2210
Is Sole Proprietor?:No
Enumeration Date:2008-06-04
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3562363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4978OtherMEDICAID GROUP
SCNP1390Medicaid
SCNP1390Medicaid