Healthcare Provider Details

I. General information

NPI: 1063463537
Provider Name (Legal Business Name): DOREEN MARY MASSEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 02/24/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 RIBAUT RD
PORT ROYAL SC
29935-1403
US

IV. Provider business mailing address

1510 RIBAUT RD
PORT ROYAL SC
29935-1403
US

V. Phone/Fax

Practice location:
  • Phone: 843-770-0676
  • Fax:
Mailing address:
  • Phone: 437-700-6768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN115838
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number24477
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: