Healthcare Provider Details

I. General information

NPI: 1982647525
Provider Name (Legal Business Name): JACQUELYN B WALDRON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22580 HIGHWAY 76 E SUITE 100
LAURENS SC
29360-8439
US

IV. Provider business mailing address

22580 HIGHWAY 76 E SUITE 100
LAURENS SC
29360-8439
US

V. Phone/Fax

Practice location:
  • Phone: 864-833-5986
  • Fax: 864-833-0599
Mailing address:
  • Phone: 864-833-5986
  • Fax: 864-833-0599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR40094
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: