Healthcare Provider Details

I. General information

NPI: 1508676099
Provider Name (Legal Business Name): KENDELL CANTRELL MATURE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22580 HIGHWAY 76 E STE 300
LAURENS SC
29360-8460
US

IV. Provider business mailing address

7310 SAINT LUKES CHURCH RD
PROSPERITY SC
29127-7125
US

V. Phone/Fax

Practice location:
  • Phone: 864-725-4673
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMPA.5463
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: