Healthcare Provider Details

I. General information

NPI: 1932776077
Provider Name (Legal Business Name): MRS. DELLARESE LEE PRIESTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DELLARESE LEE HERBERT

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6437 GARNERS FERRY RD
COLUMBIA SC
29209-1638
US

IV. Provider business mailing address

122 DRAKEWOOD DR
COLUMBIA SC
29212-8285
US

V. Phone/Fax

Practice location:
  • Phone: 800-827-1000
  • Fax:
Mailing address:
  • Phone: 404-791-6931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN202891
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN202891
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: