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NPI Code Detail

MEDICARE: MRS. KENNAH JOHNSON BREARLEY PA-C

MEDICARE: MRS. KENNAH JOHNSON BREARLEY PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant1865SC

General Provider Information

NPI Number : 1285979435
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. KENNAH JOHNSON BREARLEY PA-C
Provider Business Mailing Address
First Line : 3574 SUNSET BLVD
Second Line :
City : WEST COLUMBIA
State : SC
Zip : 29169-3044
Country : US
Telephone Number : 803-796-2500
Fax Number :
Provider Business Practice Location Address
First Line : 3574 SUNSET BLVD
Second Line :
City : WEST COLUMBIA
State : SC
Zip : 29169-3044
Country : US
Telephone Number : 803-796-2500
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/29/2012
Last Update Date : 04/30/2013

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Directions to “ MRS. KENNAH JOHNSON BREARLEY PA-C” Practice Location

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