Provider Demographics
NPI:1649247685
Name:KLECKLEY, SUZAN M (ANP)
Entity type:Individual
Prefix:MRS
First Name:SUZAN
Middle Name:M
Last Name:KLECKLEY
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 FABER PLACE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-8533
Mailing Address - Country:US
Mailing Address - Phone:843-767-9312
Mailing Address - Fax:843-767-9313
Practice Address - Street 1:3815 FABER PLACE DR
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-8533
Practice Address - Country:US
Practice Address - Phone:843-767-9312
Practice Address - Fax:843-767-9313
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN2502363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0782Medicaid
SCGP2517Medicaid
SCNP0782Medicaid
SCQ16426Medicare UPIN