Provider Demographics
NPI:1497350888
Name:WASHINGTON, ANDRE
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:WASHINGTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MYSTIC CT
Mailing Address - Street 2:
Mailing Address - City:DALZELL
Mailing Address - State:SC
Mailing Address - Zip Code:29040-8382
Mailing Address - Country:US
Mailing Address - Phone:803-236-6233
Mailing Address - Fax:
Practice Address - Street 1:20 MYSTIC CT
Practice Address - Street 2:
Practice Address - City:DALZELL
Practice Address - State:SC
Practice Address - Zip Code:29040-8382
Practice Address - Country:US
Practice Address - Phone:803-236-6233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC218782374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC218782OtherBUSINESS LICENSE