Healthcare Provider Details

I. General information

NPI: 1396157442
Provider Name (Legal Business Name): STEPHANIE FRISON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2014
Last Update Date: 05/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1369 POULTRY LN
EASTOVER SC
29044-9341
US

IV. Provider business mailing address

PO BOX 323
EASTOVER SC
29044-0323
US

V. Phone/Fax

Practice location:
  • Phone: 803-466-8005
  • Fax:
Mailing address:
  • Phone: 803-466-8005
  • Fax: 803-353-3884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number12171-C07
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: