Healthcare Provider Details

I. General information

NPI: 1306189303
Provider Name (Legal Business Name): ASHLEY DURRELL RN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 LAUREL ST
COLUMBIA SC
29201-2514
US

IV. Provider business mailing address

1308 LAUREL ST
COLUMBIA SC
29201-2514
US

V. Phone/Fax

Practice location:
  • Phone: 803-931-8166
  • Fax:
Mailing address:
  • Phone: 803-931-8166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number200172
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number22705
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: