Healthcare Provider Details

I. General information

NPI: 1609062108
Provider Name (Legal Business Name): KELLY ANNE TAYLOR HEADLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 SEVEN FARMS DR STE 108B
DANIEL ISLAND SC
29492-8932
US

IV. Provider business mailing address

PO BOX 751461
CHARLOTTE NC
28275-1461
US

V. Phone/Fax

Practice location:
  • Phone: 854-500-2326
  • Fax:
Mailing address:
  • Phone: 843-792-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1544
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: