=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275991309
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FREEDOM LEE PROCTOR CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2016
-----------------------------------------------------
Last Update Date | 07/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1516 VILLAGE HARBOR DR
-----------------------------------------------------
City | LAKE WYLIE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29710-9060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-752-4200
-----------------------------------------------------
Fax | 803-752-4300
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 743 IRISH GREEN DR
-----------------------------------------------------
City | CLOVER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29710-6076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-712-6880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | SP015911
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 24909
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------