Healthcare Provider Details

I. General information

NPI: 1679918593
Provider Name (Legal Business Name): MS. LIDIE DORN COLLIER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2013
Last Update Date: 05/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 PERRY ST
CHARLESTON SC
29403-4739
US

IV. Provider business mailing address

2 PERRY ST
CHARLESTON SC
29403-4739
US

V. Phone/Fax

Practice location:
  • Phone: 843-724-7262
  • Fax: 843-720-3128
Mailing address:
  • Phone: 843-724-7262
  • Fax: 843-720-3128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number94773
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: