Healthcare Provider Details

I. General information

NPI: 1649388513
Provider Name (Legal Business Name): KATHLEEN M KELLEY PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1952 LONG GROVE DR SUITE 202
MT PLEASANT SC
29464
US

IV. Provider business mailing address

2051 CHARLIE HALL BLVD
CHARLESTON SC
29414
US

V. Phone/Fax

Practice location:
  • Phone: 843-971-2992
  • Fax: 843-971-2998
Mailing address:
  • Phone: 843-573-2535
  • Fax: 843-573-2534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1877
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: