Provider Demographics
NPI:1144947391
Name:BISTLINE, KELLY M (APRN)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:M
Last Name:BISTLINE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BONNEAU
Mailing Address - State:SC
Mailing Address - Zip Code:29431-5013
Mailing Address - Country:US
Mailing Address - Phone:843-825-3404
Mailing Address - Fax:
Practice Address - Street 1:1401 MAIN ST
Practice Address - Street 2:
Practice Address - City:BONNEAU
Practice Address - State:SC
Practice Address - Zip Code:29431-5013
Practice Address - Country:US
Practice Address - Phone:843-825-3404
Practice Address - Fax:843-825-3407
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26733363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily