Provider Demographics
NPI:1538628110
Name:EASTERGARD, KELLY TAYLOR (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:TAYLOR
Last Name:EASTERGARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 S VAN LINGLE MUNGO BLVD
Mailing Address - Street 2:
Mailing Address - City:PAGELAND
Mailing Address - State:SC
Mailing Address - Zip Code:29728-1950
Mailing Address - Country:US
Mailing Address - Phone:843-675-5000
Mailing Address - Fax:843-675-5003
Practice Address - Street 1:222 S VAN LINGLE MUNGO BLVD
Practice Address - Street 2:
Practice Address - City:PAGELAND
Practice Address - State:SC
Practice Address - Zip Code:29728-1950
Practice Address - Country:US
Practice Address - Phone:843-675-5000
Practice Address - Fax:843-675-5003
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23867363L00000X, 363LF0000X
NC511574363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner