1376915934 NPI number — MRS. TINA RENELL GOETHIE-LYONS APRN, MSN, FNP-BC

Table of content: MRS. TINA RENELL GOETHIE-LYONS APRN, MSN, FNP-BC (NPI 1376915934)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376915934 NPI number — MRS. TINA RENELL GOETHIE-LYONS APRN, MSN, FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOETHIE-LYONS
Provider First Name:
TINA
Provider Middle Name:
RENELL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN, MSN, FNP-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:
1376915934
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 357
Provider Second Line Business Mailing Address:
721 N. OKATIE HWY, OKATIE, SC 29909
Provider Business Mailing Address City Name:
RIDGELAND
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29936-2605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-987-7400
Provider Business Mailing Address Fax Number:
843-986-0566

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
719 OKATIE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKATIE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29909-3963
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-987-7400
Provider Business Practice Location Address Fax Number:
843-986-0566
Provider Enumeration Date:
10/22/2015

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:  APN.19824.RX , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0808X , with the licence number: APN.19824.RX , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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