Healthcare Provider Details

I. General information

NPI: 1750475752
Provider Name (Legal Business Name): ELIZABETH T TEDFORD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240C CENTRAL AVE
SUMMERVILLE SC
29483-3148
US

IV. Provider business mailing address

1240C CENTRAL AVE
SUMMERVILLE SC
29483-3148
US

V. Phone/Fax

Practice location:
  • Phone: 843-821-8787
  • Fax: 843-821-8799
Mailing address:
  • Phone: 843-821-8787
  • Fax: 843-821-8799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2872
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: