Provider Demographics
NPI:1548913213
Name:THUMMA, KELLY JANE (APRN)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:JANE
Last Name:THUMMA
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 1:920 DOUG WHITE DR STE 510
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4183
Mailing Address - Country:US
Mailing Address - Phone:843-497-7772
Mailing Address - Fax:
Practice Address - Street 1:920 DOUG WHITE DR STE 510
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4183
Practice Address - Country:US
Practice Address - Phone:843-497-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25776363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner