Healthcare Provider Details

I. General information

NPI: 1154748424
Provider Name (Legal Business Name): DIANE MCDONALD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2014
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 CHURCH ST
CAMDEN SC
29020
US

IV. Provider business mailing address

6114 HAMPTON LEAS LN
COLUMBIA SC
29209-1952
US

V. Phone/Fax

Practice location:
  • Phone: 803-425-6012
  • Fax: 803-424-1611
Mailing address:
  • Phone: 803-425-6012
  • Fax: 803-424-1611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number91813
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: