1962479170 NPI number — MRS. K. PATRICIA MILLER DERAJTYS FNP

Table of content: MRS. K. PATRICIA MILLER DERAJTYS FNP (NPI 1962479170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962479170 NPI number — MRS. K. PATRICIA MILLER DERAJTYS FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILLER DERAJTYS
Provider First Name:
K. PATRICIA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DERAJTYS
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
PATRICIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1962479170
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1278 N LAFAYETTE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUMTER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29150-2964
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-774-4500
Provider Business Mailing Address Fax Number:
803-774-4641

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1278 N LAFAYETTE DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-774-4500
Provider Business Practice Location Address Fax Number:
803-774-4641
Provider Enumeration Date:
03/07/2006

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: 363L00000X , with the licence number:  236 , 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: NP0840 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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