1285389163 NPI number — MELISSA FAYE HARE AGACNP-BC

Table of content: MELISSA FAYE HARE AGACNP-BC (NPI 1285389163)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285389163 NPI number — MELISSA FAYE HARE AGACNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARE
Provider First Name:
MELISSA
Provider Middle Name:
FAYE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AGACNP-BC
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:
1285389163
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 SINGLETON RIDGE RD
Provider Second Line Business Mailing Address:
ATTENTION PNS CREDENTIALING
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29526-9142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-234-6946
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2376 CYPRESS CIR
Provider Second Line Business Practice Location Address:
STE 203
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29526-8994
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-347-6038
Provider Business Practice Location Address Fax Number:
843-347-9808
Provider Enumeration Date:
02/18/2022

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: 363LA2100X , with the licence number:  25804 , 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)

  • Identifier: NP8464 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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