Healthcare Provider Details

I. General information

NPI: 1407340094
Provider Name (Legal Business Name): MRS. PRINSCILLIA DENISE SUMPTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 05/06/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 CHILDREN LANE
ST. STEPHENS SC
29476
US

IV. Provider business mailing address

PO BOX 9
RUSSELLVILLE SC
29476-0009
US

V. Phone/Fax

Practice location:
  • Phone: 843-518-7238
  • Fax:
Mailing address:
  • Phone: 843-518-7238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number124100
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number116708
License Number StateSC
# 6
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number124100
License Number StateSC
# 7
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: