Healthcare Provider Details

I. General information

NPI: 1851716708
Provider Name (Legal Business Name): KENNA COURTNEY STEPHANIE ALTOBELLO APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2014
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 SALUDA POINTE DR
LEXINGTON SC
29072-7295
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-296-7846
  • Fax: 803-296-9699
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041323580
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number18805
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: