Healthcare Provider Details

I. General information

NPI: 1417298183
Provider Name (Legal Business Name): KELLY DELAINE FRAZIER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2013
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 HOLLY ST
ORANGEBURG SC
29115-4930
US

IV. Provider business mailing address

970 HOLLY ST
ORANGEBURG SC
29115-4930
US

V. Phone/Fax

Practice location:
  • Phone: 803-531-2722
  • Fax: 803-531-2743
Mailing address:
  • Phone: 803-531-2722
  • Fax: 803-531-2743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18113
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: