Basic Information
| Provider Information | |||||||||
| NPI: | 1851716708 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALTOBELLO | ||||||||
| FirstName: | KENNA | ||||||||
| MiddleName: | COURTNEY STEPHANIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 743904 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 SALUDA POINTE DR | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290727295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967846 | ||||||||
| FaxNumber: | 8032969699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2014 | ||||||||
| LastUpdateDate: | 06/01/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041323580 | IL | N | Nursing Service Providers | Registered Nurse | 364SA2200X | 18805 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | NP4873 | 05 | SC | MEDICAID |