Provider Demographics
NPI:1003253089
Name:BINGHAM, JENNIE (RN)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:BINGHAM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 WATTLING RD
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29170-2245
Mailing Address - Country:US
Mailing Address - Phone:803-739-4175
Mailing Address - Fax:
Practice Address - Street 1:361 WATTLING RD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29170-2245
Practice Address - Country:US
Practice Address - Phone:803-739-4175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRN.76219163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool