Healthcare Provider Details

I. General information

NPI: 1861052425
Provider Name (Legal Business Name): KENDREA ROBINSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KENDREA MOORE APRN

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 01/04/2021
Certification Date: 01/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 CENTER ST STE 100
WEST COLUMBIA SC
29169-6749
US

IV. Provider business mailing address

2142 EATON CIR
FLORENCE SC
29501-6429
US

V. Phone/Fax

Practice location:
  • Phone: 800-491-0909
  • Fax:
Mailing address:
  • Phone: 843-245-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22935
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: