Provider Demographics
NPI:1366829368
Name:WASHINGTON, ERVENA (PCA)
Entity Type:Individual
Prefix:MRS
First Name:ERVENA
Middle Name:
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:PCA
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 973
Mailing Address - Street 2:
Mailing Address - City:RIDGEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29472-0973
Mailing Address - Country:US
Mailing Address - Phone:843-376-1037
Mailing Address - Fax:
Practice Address - Street 1:177 QUEEN DR
Practice Address - Street 2:
Practice Address - City:RIDGEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29472-8427
Practice Address - Country:US
Practice Address - Phone:843-376-1037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide