Provider Demographics
NPI:1609630961
Name:DEWALT, BRAE
Entity Type:Individual
Prefix:MRS
First Name:BRAE
Middle Name:
Last Name:DEWALT
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 1:2097 PIMLICO DR
Mailing Address - Street 2:
Mailing Address - City:RIDGEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29472-5951
Mailing Address - Country:US
Mailing Address - Phone:619-721-5407
Mailing Address - Fax:
Practice Address - Street 1:101 POTTERY CIR
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-8095
Practice Address - Country:US
Practice Address - Phone:843-771-2934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician