Healthcare Provider Details

I. General information

NPI: 1700173390
Provider Name (Legal Business Name): VICKY ANN JERVIS-ROZYCKI RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 07/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 TAYLOR ST SUITE 4-E
COLUMBIA SC
29201-2923
US

IV. Provider business mailing address

1333 TAYLOR ST SUITE 4-E
COLUMBIA SC
29201-2923
US

V. Phone/Fax

Practice location:
  • Phone: 803-296-8906
  • Fax: 803-296-8908
Mailing address:
  • Phone: 803-296-8906
  • Fax: 803-296-8908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0900X
TaxonomyEnterostomal Therapy Registered Nurse
License Number97811
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: