Provider Demographics
NPI:1366930141
Name:KELLOGG, ELIZABETH RYAN (FNP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:RYAN
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 HATTERAS WAY
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29153-1966
Mailing Address - Country:US
Mailing Address - Phone:717-880-7262
Mailing Address - Fax:
Practice Address - Street 1:1105 N LAFAYETTE DR STE A
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-2984
Practice Address - Country:US
Practice Address - Phone:803-934-8833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21789207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine