Healthcare Provider Details

I. General information

NPI: 1740201417
Provider Name (Legal Business Name): MRS. JEANINE KHOURY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 MONTICELLO RD
COLUMBIA SC
29203-4156
US

IV. Provider business mailing address

4605 MONTICELLO RD
COLUMBIA SC
29203-4156
US

V. Phone/Fax

Practice location:
  • Phone: 803-252-7001
  • Fax: 803-252-5219
Mailing address:
  • Phone: 803-252-7001
  • Fax: 803-252-5219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1215
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: