Basic Information
| Provider Information | |||||||||
| NPI: | 1396257325 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOSTIC | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | HODGE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645228603 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 701 MEDICAL PARK DR STE 301 | ||||||||
| Address2: | |||||||||
| City: | HARTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295504779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433835978 | ||||||||
| FaxNumber: | 8433835977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2017 | ||||||||
| LastUpdateDate: | 03/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 21427 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 21427 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | NP4882 | 05 | SC | MEDICAID |