Healthcare Provider Details

I. General information

NPI: 1205194594
Provider Name (Legal Business Name): ANNA M MOAK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNA M CRAFT

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 2ND LOOP RD
FLORENCE SC
29501-6123
US

IV. Provider business mailing address

1920 2ND LOOP RD
FLORENCE SC
29501-6123
US

V. Phone/Fax

Practice location:
  • Phone: 843-678-9777
  • Fax: 843-665-2814
Mailing address:
  • Phone: 843-678-9777
  • Fax: 843-665-2814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License Number17764
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number17764
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: