Healthcare Provider Details

I. General information

NPI: 1780141069
Provider Name (Legal Business Name): ASHLEIGH LYNN KINON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2019
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 WACCAMAW MEDICAL PARK CT
CONWAY SC
29526-8965
US

IV. Provider business mailing address

166 WACCAMAW MEDICAL PARK CT
CONWAY SC
29526-8965
US

V. Phone/Fax

Practice location:
  • Phone: 843-449-0453
  • Fax: 843-449-9531
Mailing address:
  • Phone: 843-449-0453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number22626
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: