Healthcare Provider Details

I. General information

NPI: 1346684933
Provider Name (Legal Business Name): LOGAN JESSICA CAMP REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

4801 HIGHWAY 9
INMAN SC
29349-8003
US

IV. Provider business mailing address

4801 HIGHWAY 9
INMAN SC
29349-8003
US

V. Phone/Fax

Practice location:
  • Phone: 864-578-5954
  • Fax: 864-599-5489
Mailing address:
  • Phone: 864-578-5954
  • Fax: 864-599-5489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number204836
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: