Healthcare Provider Details

I. General information

NPI: 1295300945
Provider Name (Legal Business Name): KYNDRA MARIE HUMPHREYS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 02/05/2024
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 HIGHWAY 57 N
LITTLE RIVER SC
29566-7050
US

IV. Provider business mailing address

700 21ST AVE N
MYRTLE BEACH SC
29577-7400
US

V. Phone/Fax

Practice location:
  • Phone: 843-915-5654
  • Fax:
Mailing address:
  • Phone: 843-915-4836
  • Fax: 843-448-7499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number261563
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: