Healthcare Provider Details

I. General information

NPI: 1821730649
Provider Name (Legal Business Name): CASEY BERRY RIDGELL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CASEY MIRANDA BERRY RN

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 01/24/2024
Certification Date: 01/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 CLEMSON RD
COLUMBIA SC
29229-7925
US

IV. Provider business mailing address

378 FANNIE BLACK RD
PROSPERITY SC
29127-6943
US

V. Phone/Fax

Practice location:
  • Phone: 803-438-3800
  • Fax:
Mailing address:
  • Phone: 803-603-7676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number25903
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: