Provider Demographics
NPI:1417929134
Name:DOUGLASS, JANET L (FNP)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:L
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1228 HARDEN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-1800
Mailing Address - Country:US
Mailing Address - Phone:803-733-5969
Mailing Address - Fax:803-753-5591
Practice Address - Street 1:12 MEADOWLAKE RD
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:SC
Practice Address - Zip Code:29015-8997
Practice Address - Country:US
Practice Address - Phone:803-945-7595
Practice Address - Fax:803-945-7596
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26995363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCFQC030Medicaid
SCFQC043Medicaid
SCNP0733Medicaid
WI421892Medicare Oscar/Certification
SCAA06577131Medicare PIN
SCNP0733Medicaid
SCQ26937Medicare UPIN
SCFQC030Medicaid