Healthcare Provider Details

I. General information

NPI: 1922632702
Provider Name (Legal Business Name): LYN-MARIE KUBALL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2020
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4303 LIVE OAK DR
LITTLE RIVER SC
29566-9138
US

IV. Provider business mailing address

PO BOX 547
LITTLE RIVER SC
29566-0547
US

V. Phone/Fax

Practice location:
  • Phone: 843-663-8000
  • Fax: 843-663-8123
Mailing address:
  • Phone: 843-663-8000
  • Fax: 843-663-8123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number105268
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: