Healthcare Provider Details

I. General information

NPI: 1346588795
Provider Name (Legal Business Name): MAZIE ELIZABETH GRAHAM R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2013
Last Update Date: 01/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 PRINCE ST
GEORGETOWN SC
29440-2925
US

IV. Provider business mailing address

2317 PRINCE ST
GEORGETOWN SC
29440-2925
US

V. Phone/Fax

Practice location:
  • Phone: 843-240-2061
  • Fax: 843-527-4838
Mailing address:
  • Phone: 843-240-2061
  • Fax: 843-527-4838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberR26610
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: