Healthcare Provider Details

I. General information

NPI: 1548600547
Provider Name (Legal Business Name): MARY LAUREL VARGHESE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2013
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 S POINSETT HWY TRAVELERS REST INTERNAL MEDICINE
TRAVELERS REST SC
29690-1822
US

IV. Provider business mailing address

PO BOX 743294
ATLANTA GA
30374-3294
US

V. Phone/Fax

Practice location:
  • Phone: 864-834-7834
  • Fax: 864-834-7477
Mailing address:
  • Phone: 864-834-7834
  • Fax: 864-834-7477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number20185
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: