Provider Demographics
NPI:1881139699
Name:KETHE, KRISTY JO (CRNA, MNA)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:JO
Last Name:KETHE
Suffix:
Gender:F
Credentials:CRNA, MNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8090 PLEASANT POINT LN
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-4170
Mailing Address - Country:US
Mailing Address - Phone:843-283-9494
Mailing Address - Fax:
Practice Address - Street 1:555 E CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2617
Practice Address - Country:US
Practice Address - Phone:843-777-2275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-03
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC210194163W00000X
SC390200000X
SC21063367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN2683Medicaid