1023453248 NPI number — MRS. GWENDOLYN BULLARD LEGETTE REGISTERED NURSE

Table of content: MRS. GWENDOLYN BULLARD LEGETTE REGISTERED NURSE (NPI 1023453248)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023453248 NPI number — MRS. GWENDOLYN BULLARD LEGETTE REGISTERED NURSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEGETTE
Provider First Name:
GWENDOLYN
Provider Middle Name:
BULLARD
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
REGISTERED NURSE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023453248
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6641 S HWY 41
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29571
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-362-3500
Provider Business Mailing Address Fax Number:
843-362-3506

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6641 S HIGHWAY 41
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29571-8400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-362-3500
Provider Business Practice Location Address Fax Number:
843-362-3506
Provider Enumeration Date:
05/01/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  35781 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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