Healthcare Provider Details

I. General information

NPI: 1659587764
Provider Name (Legal Business Name): DIANNE LANDIS BRETZ FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANE HURST NP

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 E MEDICAL LN STE 300
WEST COLUMBIA SC
29169-4848
US

IV. Provider business mailing address

PO BOX 6069
WEST COLUMBIA SC
29171-6069
US

V. Phone/Fax

Practice location:
  • Phone: 803-936-8100
  • Fax: 803-936-8130
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number1594
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: