Healthcare Provider Details

I. General information

NPI: 1588815021
Provider Name (Legal Business Name): JAMES ROBERT MYNATT FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAMES MYNATT

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 REVOLUTIONARY TRAIL
FAIRFAX SC
29827
US

IV. Provider business mailing address

86 WREN ST
BARNWELL SC
29812
US

V. Phone/Fax

Practice location:
  • Phone: 803-632-2533
  • Fax: 803-632-2451
Mailing address:
  • Phone: 803-259-5762
  • Fax: 803-259-3250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF1512
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: