Healthcare Provider Details

I. General information

NPI: 1578850947
Provider Name (Legal Business Name): KELLY LYNN WARNOCK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 07/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 HIGHWAY 1 S SUITE 300
LUGOFF SC
29078-8966
US

IV. Provider business mailing address

103 SOUTH MAIN STREET
BETHUNE SC
29009
US

V. Phone/Fax

Practice location:
  • Phone: 803-438-0867
  • Fax: 803-438-4391
Mailing address:
  • Phone: 843-334-6551
  • Fax: 803-438-4391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF4476
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: