Healthcare Provider Details

I. General information

NPI: 1821850447
Provider Name (Legal Business Name): KELLY METTS HUMPHRIES APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1043 BLACK TOM RD
MONCKS CORNER SC
29461-8816
US

IV. Provider business mailing address

1043 BLACK TOM RD
MONCKS CORNER SC
29461-8816
US

V. Phone/Fax

Practice location:
  • Phone: 843-860-7535
  • Fax:
Mailing address:
  • Phone: 843-860-7535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number28247
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License NumberAPN28247RX
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN28247RX
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: