Provider Demographics
NPI:1285979435
Name:BREARLEY, KENNAH JOHNSON (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KENNAH
Middle Name:JOHNSON
Last Name:BREARLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KENNAH
Other - Middle Name:LOVE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3574 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3044
Mailing Address - Country:US
Mailing Address - Phone:803-796-2500
Mailing Address - Fax:
Practice Address - Street 1:3574 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3044
Practice Address - Country:US
Practice Address - Phone:803-796-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-29
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1865363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant