Provider Demographics
NPI:1154618882
Name:TRUESDALE, KELLY ANNE (DO)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANNE
Last Name:TRUESDALE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:803-732-0963
Mailing Address - Fax:803-732-1406
Practice Address - Street 1:7033 SAINT ANDREWS RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1179
Practice Address - Country:US
Practice Address - Phone:803-732-0963
Practice Address - Fax:803-732-1406
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60524953207Q00000X
SD8612207Q00000X
SC83843207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2044716Medicaid