Provider Demographics
NPI:1548600547
Name:VARGHESE, MARY LAUREL (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LAUREL
Last Name:VARGHESE
Suffix:
Gender:F
Credentials:NP-C
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 743294
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3294
Mailing Address - Country:US
Mailing Address - Phone:864-834-7834
Mailing Address - Fax:864-834-7477
Practice Address - Street 1:6 S POINSETT HWY
Practice Address - Street 2:TRAVELERS REST INTERNAL MEDICINE
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-1822
Practice Address - Country:US
Practice Address - Phone:864-834-7834
Practice Address - Fax:864-834-7477
Is Sole Proprietor?:No
Enumeration Date:2013-07-05
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20185363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003140025AMedicaid
SCNP3996Medicaid
GA202I506197Medicare PIN
SCNP3996Medicaid