Provider Demographics
NPI:1669815510
Name:SMALL, JULIE C (LPN)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:C
Last Name:SMALL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MULLINS
Mailing Address - State:SC
Mailing Address - Zip Code:29574-2532
Mailing Address - Country:US
Mailing Address - Phone:843-464-3740
Mailing Address - Fax:
Practice Address - Street 1:200 BROAD STREET
Practice Address - Street 2:
Practice Address - City:MULLINS
Practice Address - State:SC
Practice Address - Zip Code:29574
Practice Address - Country:US
Practice Address - Phone:843-464-3740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCP39017164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP39017Medicaid