Healthcare Provider Details

I. General information

NPI: 1881485662
Provider Name (Legal Business Name): SRP MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2025
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 BLUEWATER WAY
CHARLESTON SC
29414-7923
US

IV. Provider business mailing address

742 SAINT ANDREWS BLVD
CHARLESTON SC
29407-7169
US

V. Phone/Fax

Practice location:
  • Phone: 407-516-3756
  • Fax:
Mailing address:
  • Phone: 407-516-3756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SONYA R PUCKETT
Title or Position: OWNER
Credential: APRN-AGACNP
Phone: 407-516-3756