Healthcare Provider Details

I. General information

NPI: 1265207229
Provider Name (Legal Business Name): ANGEL OAK PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3312 MAYBANK HWY STE B
JOHNS ISLAND SC
29455-4818
US

IV. Provider business mailing address

2911 WATERLEAF RD
JOHNS ISLAND SC
29455-3176
US

V. Phone/Fax

Practice location:
  • Phone: 843-894-3490
  • Fax: 833-450-6022
Mailing address:
  • Phone: 248-760-4587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KELLI E JOHNSTON
Title or Position: PEDIATRICIAN/OWNER
Credential: DO
Phone: 248-760-4587