Provider Demographics
NPI:1649239880
Name:HORNE, EVELYN BRANTLEY (NP)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:BRANTLEY
Last Name:HORNE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9 HAWTHORNE PARK CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3194
Mailing Address - Country:US
Mailing Address - Phone:864-603-5600
Mailing Address - Fax:864-603-5601
Practice Address - Street 1:312 HARRISON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29680-7133
Practice Address - Country:US
Practice Address - Phone:864-603-5600
Practice Address - Fax:864-603-5601
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2203363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0906Medicaid
SCNP0906Medicaid
SCP00276758Medicare PIN
SCP23125Medicare PIN