Provider Demographics
NPI:1861775264
Name:GAGNE, KELLI P (APRN)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:P
Last Name:GAGNE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:331 E MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-5384
Mailing Address - Country:US
Mailing Address - Phone:704-438-0687
Mailing Address - Fax:844-308-7996
Practice Address - Street 1:331 E MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-5384
Practice Address - Country:US
Practice Address - Phone:704-438-0687
Practice Address - Fax:844-308-7996
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4815363LP0808X
NC5008661363LP0808X
SC20033363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health