MEDICARE: KIM GOSNELL NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	21	SC

General Provider Information

NPI Number	:	1710982772
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM GOSNELL NP

Provider Business Mailing Address
First Line	:	1 INDEPENDENCE PT STE 212
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29615-4536
Country	:	US
Telephone Number	:	864-797-6308
Fax Number	:

Provider Business Practice Location Address
First Line	:	107 OMNI DR STE A
Second Line	:
City	:	SENECA
State	:	SC
Zip	:	29672-9448
Country	:	US
Telephone Number	:	864-885-7886
Fax Number	:	864-885-7890

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	04/30/2018

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