Healthcare Provider Details

I. General information

NPI: 1477717551
Provider Name (Legal Business Name): NANETTE C KELLY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 FARRAR DR
CONWAY SC
29526-8747
US

IV. Provider business mailing address

8121 ROURK ST
MYRTLE BEACH SC
29572-4128
US

V. Phone/Fax

Practice location:
  • Phone: 843-234-1660
  • Fax: 843-234-1661
Mailing address:
  • Phone: 843-692-5000
  • Fax: 843-692-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17929
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: