Healthcare Provider Details

I. General information

NPI: 1235573551
Provider Name (Legal Business Name): SALLY BETHEA WIEDEMANN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 04/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 CENTER ST
GREENWOOD SC
29649-1126
US

IV. Provider business mailing address

660 CENTER ST
GREENWOOD SC
29649-1126
US

V. Phone/Fax

Practice location:
  • Phone: 864-941-3447
  • Fax:
Mailing address:
  • Phone: 864-941-3447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number25939
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: