Provider Demographics
NPI:1912624206
Name:MEDLIN, KAYLA JO NIX (APRN)
Entity Type:Individual
Prefix:
First Name:KAYLA JO
Middle Name:NIX
Last Name:MEDLIN
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:PO BOX 120
Mailing Address - Street 2:
Mailing Address - City:BAMBERG
Mailing Address - State:SC
Mailing Address - Zip Code:29003-0120
Mailing Address - Country:US
Mailing Address - Phone:803-245-5168
Mailing Address - Fax:803-245-6275
Practice Address - Street 1:2113 MAIN HWY
Practice Address - Street 2:
Practice Address - City:BAMBERG
Practice Address - State:SC
Practice Address - Zip Code:29003-2705
Practice Address - Country:US
Practice Address - Phone:803-245-5168
Practice Address - Fax:803-245-6275
Is Sole Proprietor?:No
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26729363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC101027013OtherDRIVERS LICENSE