Provider Demographics
NPI:1114970712
Name:POYNER, PHYLLIS C (NP)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:C
Last Name:POYNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7531
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-7531
Mailing Address - Country:US
Mailing Address - Phone:803-256-2500
Mailing Address - Fax:803-758-1726
Practice Address - Street 1:1410 BLANDING ST STE 102
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2967
Practice Address - Country:US
Practice Address - Phone:803-256-2500
Practice Address - Fax:803-758-1726
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20563364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0130Medicaid
SCSC61126580Medicare PIN
SCS957386580Medicare PIN
S95738Medicare UPIN