Healthcare Provider Details

I. General information

NPI: 1316652308
Provider Name (Legal Business Name): JULIE NICOLE KOSATSCHENKO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2023
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 WISE RD
CONWAY SC
29526-5521
US

IV. Provider business mailing address

436 WILLIAM NOBLES RD
AYNOR SC
29511-2803
US

V. Phone/Fax

Practice location:
  • Phone: 843-365-8884
  • Fax: 843-365-6685
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26872
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: