Healthcare Provider Details

I. General information

NPI: 1992727101
Provider Name (Legal Business Name): MICHELLE LEE CUDD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE LEE FULLER

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 WACCAMAW MEDICAL PARK DR
CONWAY SC
29526-8903
US

IV. Provider business mailing address

2450 HUNTERS TRL
MYRTLE BEACH SC
29588-8411
US

V. Phone/Fax

Practice location:
  • Phone: 843-347-5060
  • Fax:
Mailing address:
  • Phone: 843-236-7884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number91974
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: