Healthcare Provider Details

I. General information

NPI: 1861031031
Provider Name (Legal Business Name): NICOLE MARIE KIZER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2020
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W BUTLER RD
MAULDIN SC
29662-2585
US

IV. Provider business mailing address

300 W BUTLER RD
MAULDIN SC
29662-2585
US

V. Phone/Fax

Practice location:
  • Phone: 864-277-8300
  • Fax: 864-288-8722
Mailing address:
  • Phone: 864-277-8300
  • Fax: 864-288-8722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number23581
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: