1871994327 NPI number — JO LINDA HAMMETT

Table of content: JO LINDA HAMMETT (NPI 1871994327)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871994327 NPI number — JO LINDA HAMMETT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAMMETT
Provider First Name:
JO
Provider Middle Name:
LINDA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REYES
Provider Other First Name:
JO
Provider Other Middle Name:
LINDA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN, FNP-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871994327
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1624 MAIN STREET
Provider Second Line Business Mailing Address:
AGAPE SENIOR PRIMARY CARE, INC., DBA AGAPE PHYSICIANS C
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-454-0365
Provider Business Mailing Address Fax Number:
803-404-6000

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
529 MILLS AVENUE
Provider Second Line Business Practice Location Address:
AGAPE PHYSICIANS CARE
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-751-6430
Provider Business Practice Location Address Fax Number:
864-751-6424
Provider Enumeration Date:
09/15/2014

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:  19057 , 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: NP2930 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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