=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447348693
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEREDITH LAURETTA MONA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2006
-----------------------------------------------------
Last Update Date | 04/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2611 LIBERTY HILL RD
-----------------------------------------------------
City | CAMDEN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29020-1871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-432-5323
-----------------------------------------------------
Fax | 803-713-3978
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 N. MAGNOLIA STREET
-----------------------------------------------------
City | SUMTER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29151-4943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-775-9364
-----------------------------------------------------
Fax | 803-773-6615
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 28696
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------