MEDICARE: STACY LANE MERRITT NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2100X	Acute Care Nurse Practitioner	4456	SC
2	363LF0000X	Family Nurse Practitioner	4456	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1124180732	OTHER	SC	FASTER CARE NPI

General Provider Information

NPI Number	:	1790081941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY LANE MERRITT NP

Provider Business Mailing Address
First Line	:	3440 DECLARATION BLVD
Second Line	:
City	:	SUMTER
State	:	SC
Zip	:	29154-8139
Country	:	US
Telephone Number	:	803-905-3278
Fax Number	:	803-905-3282

Provider Business Practice Location Address
First Line	:	3440 DECLARATION BLVD
Second Line	:
City	:	SUMTER
State	:	SC
Zip	:	29154-8139
Country	:	US
Telephone Number	:	803-905-3278
Fax Number	:	803-905-3282

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2011
Last Update Date	:	03/22/2011

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