Healthcare Provider Details

I. General information

NPI: 1275923260
Provider Name (Legal Business Name): TIFFANY KENNEDY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2015
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3248 EDGELAND HWY
RICHBURG SC
29729-9478
US

IV. Provider business mailing address

2139 BROOKFIELD LN
LANCASTER SC
29720-8872
US

V. Phone/Fax

Practice location:
  • Phone: 803-789-6111
  • Fax: 803-789-6118
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19284
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: