Healthcare Provider Details

I. General information

NPI: 1255974655
Provider Name (Legal Business Name): KAITLYN B BEVERLY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAITLYN T BROWN

II. Dates (important events)

Enumeration Date: 10/18/2019
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 SINGLETON RIDGE ROAD
CONWAY SC
29526-9154
US

IV. Provider business mailing address

300 SINGLETON RIDGE ROAD ATTENTION PATIENT ACCOUNTING
CONWAY SC
29526-9142
US

V. Phone/Fax

Practice location:
  • Phone: 843-347-7300
  • Fax: 843-347-8459
Mailing address:
  • Phone: 843-234-6946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: