Healthcare Provider Details

I. General information

NPI: 1033711981
Provider Name (Legal Business Name): KRISTINA M DIBARTOLO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2020
Last Update Date: 03/04/2022
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 SPRINGVIEW LN # A
SUMMERVILLE SC
29485-8153
US

IV. Provider business mailing address

90 SPRINGVIEW LN # A
SUMMERVILLE SC
29485-8153
US

V. Phone/Fax

Practice location:
  • Phone: 843-832-9113
  • Fax: 843-832-9114
Mailing address:
  • Phone: 843-832-9113
  • Fax: 843-832-9114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number25819
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2300900
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: