Healthcare Provider Details

I. General information

NPI: 1376103564
Provider Name (Legal Business Name): JEANA NICOLE RICHARDSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 INDUSTRIAL PARK RD
CONWAY SC
29526-5482
US

IV. Provider business mailing address

262 OAK LANDING DR
CONWAY SC
29527-7787
US

V. Phone/Fax

Practice location:
  • Phone: 834-915-8800
  • Fax:
Mailing address:
  • Phone: 843-283-9807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number211857
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: