Provider Demographics
NPI:1578982377
Name:MIMS, DORENDA
Entity Type:Individual
Prefix:
First Name:DORENDA
Middle Name:
Last Name:MIMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 GOODSON RD
Mailing Address - Street 2:
Mailing Address - City:HARLEYVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29448-3351
Mailing Address - Country:US
Mailing Address - Phone:843-462-7766
Mailing Address - Fax:
Practice Address - Street 1:4050 BRIDGE VIEW DR
Practice Address - Street 2:STE 600
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-7488
Practice Address - Country:US
Practice Address - Phone:843-953-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC33429163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse