1275991309 NPI number — MRS. FREEDOM LEE PROCTOR CRNP

Table of content: MRS. FREEDOM LEE PROCTOR CRNP (NPI 1275991309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275991309 NPI number — MRS. FREEDOM LEE PROCTOR CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROCTOR
Provider First Name:
FREEDOM
Provider Middle Name:
LEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DEFELICE, BEVINGTON-PROCTOR
Provider Other First Name:
FREEDOM
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275991309
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
743 IRISH GREEN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLOVER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29710-6076
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-712-6880
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1516 VILLAGE HARBOR DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE WYLIE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29710-9060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-752-4200
Provider Business Practice Location Address Fax Number:
803-752-4300
Provider Enumeration Date:
02/03/2016

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: 363LF0000X , with the licence number:  SP015911 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 24909 , 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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