Healthcare Provider Details

I. General information

NPI: 1467450643
Provider Name (Legal Business Name): KATHLEEN M CHANCE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SINGLETON RIDGE RD
CONWAY SC
29526-9142
US

IV. Provider business mailing address

111 CLANCURRY PL
PAWLEYS ISLAND SC
29585-6394
US

V. Phone/Fax

Practice location:
  • Phone: 843-234-5038
  • Fax:
Mailing address:
  • Phone: 843-979-0769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number135833
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: