=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356821904
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. PAULETTE O'NEAL RUMPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2018
-----------------------------------------------------
Last Update Date | 05/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 136-4 FORUM DR 1018
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-836-8679
-----------------------------------------------------
Fax | 803-888-2007
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 416 ROYAL LINKS DR
-----------------------------------------------------
City | BLYTHEWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29016-8390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-453-7560
-----------------------------------------------------
Fax | 803-888-2007
-----------------------------------------------------
=====================================================
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 | 22045
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------