Provider Demographics
NPI:1447400171
Name:KENNICKELL, MARIA MALATANOS (PA-C)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:MALATANOS
Last Name:KENNICKELL
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 HOSPITAL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3217
Mailing Address - Country:US
Mailing Address - Phone:843-793-5182
Mailing Address - Fax:843-266-5125
Practice Address - Street 1:1300 HOSPITAL DR STE 300
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3217
Practice Address - Country:US
Practice Address - Phone:843-884-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2729363A00000X
DCPA030555363A00000X
VA0110003039363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2999PAMedicaid