Healthcare Provider Details

I. General information

NPI: 1306732631
Provider Name (Legal Business Name): VASTI ORTEGA GEDDES PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2025
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1188 STONECREST BLVD STE 110
FORT MILL SC
29708-6633
US

IV. Provider business mailing address

135 AQUINAS WAY
ROCK HILL SC
29730-0180
US

V. Phone/Fax

Practice location:
  • Phone: 803-233-3236
  • Fax:
Mailing address:
  • Phone: 910-441-8054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberPENDING
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: