Healthcare Provider Details

I. General information

NPI: 1518533058
Provider Name (Legal Business Name): KEITH TISHEEM KING FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5070 INTERNATIONAL BLVD STE 131
NORTH CHARLESTON SC
29418-6007
US

IV. Provider business mailing address

PO BOX 751649
CHARLOTTE NC
28275-1649
US

V. Phone/Fax

Practice location:
  • Phone: 843-402-5053
  • Fax: 843-724-1325
Mailing address:
  • Phone: 888-472-0043
  • Fax: 843-724-2440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number25025
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number25025
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: