Provider Demographics
NPI:1366796377
Name:CLATTERBUCK, KAYLI MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KAYLI
Middle Name:MARIE
Last Name:CLATTERBUCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAYLI
Other - Middle Name:MARIE
Other - Last Name:POLLITTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6450 SOMERSET DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-3261
Mailing Address - Country:US
Mailing Address - Phone:606-776-3247
Mailing Address - Fax:
Practice Address - Street 1:809 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4607
Practice Address - Country:US
Practice Address - Phone:843-692-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPA2357363A00000X
MO2014017611363A00000X
IL085004539363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant