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General NPI Number Information
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NPI Number | 1881485662
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Entity Type | Organization
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Legal Business Name | SRP MEDICAL LLC
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Dates
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Enumeration Date | 05/13/2025
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Last Update Date | 05/13/2025
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Provider Practice Location Address
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Address Line | 1445 BLUEWATER WAY
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City | CHARLESTON
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State | SC
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Zip | 29414-7923
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Country | US
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Telephone | 407-516-3756
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Fax |
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Provider Business Mailing Address
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Address Line | 742 SAINT ANDREWS BLVD
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City | CHARLESTON
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State | SC
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Zip | 29407-7169
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Country | US
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Telephone | 407-516-3756
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SONYA R PUCKETT
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Credential | APRN-AGACNP
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Telephone | 407-516-3756
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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