Provider Demographics
NPI:1285012716
Name:PIPENKO, VITALIY V JR (APRN)
Entity Type:Individual
Prefix:
First Name:VITALIY
Middle Name:V
Last Name:PIPENKO
Suffix:JR
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:STE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6306
Mailing Address - Fax:
Practice Address - Street 1:1809 WADE HAMPTON BLVD STE 120
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-4050
Practice Address - Country:US
Practice Address - Phone:864-522-5000
Practice Address - Fax:864-241-9275
Is Sole Proprietor?:No
Enumeration Date:2015-05-17
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19427363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP3351Medicaid
SCSC62997951Medicare PIN