Healthcare Provider Details

I. General information

NPI: 1053138891
Provider Name (Legal Business Name): KAILEY DENAJAH MATTISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 W FARIS RD
GREENVILLE SC
29605-4241
US

IV. Provider business mailing address

320 FALLS ST UNIT 503
GREENVILLE SC
29601-3555
US

V. Phone/Fax

Practice location:
  • Phone: 864-729-8330
  • Fax:
Mailing address:
  • Phone: 864-201-9517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number43579
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number43579
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: