Healthcare Provider Details

I. General information

NPI: 1861850281
Provider Name (Legal Business Name): LISA MCLAURIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2016
Last Update Date: 01/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6439 GARNERS FERRY RD
COLUMBIA SC
29209-1638
US

IV. Provider business mailing address

6439 GARNERS FERRY RD
COLUMBIA SC
29209-1638
US

V. Phone/Fax

Practice location:
  • Phone: 803-465-4022
  • Fax:
Mailing address:
  • Phone: 803-465-4022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number19850
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: