Provider Demographics
NPI:1861555690
Name:SOUTH COUNTY WELLNESS GROUP, LLC
Entity type:Organization
Organization Name:SOUTH COUNTY WELLNESS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESCRIPTIVE CLINICAL NURSE SPECIAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:PCNS
Authorized Official - Phone:401-667-7079
Mailing Address - Street 1:1130 TEN ROD RD
Mailing Address - Street 2:SUITE E302
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-4161
Mailing Address - Country:US
Mailing Address - Phone:401-667-7079
Mailing Address - Fax:
Practice Address - Street 1:1130 TEN ROD RD
Practice Address - Street 2:SUITE E302
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-4161
Practice Address - Country:US
Practice Address - Phone:401-667-7079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPPNS00010363LP0808X
RIPPNS00047363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1962597336OtherNPI
RI1043260268OtherNPI
RIQ02015Medicare UPIN
RI1962597336OtherNPI