Provider Demographics
NPI:1720363773
Name:LOVELACE, BRITTANY LONG (PA - C)
Entity Type:Individual
Prefix:MRS
First Name:BRITTANY
Middle Name:LONG
Last Name:LOVELACE
Suffix:
Gender:F
Credentials:PA - 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 630
Mailing Address - Street 2:
Mailing Address - City:PROSPERITY
Mailing Address - State:SC
Mailing Address - Zip Code:29127-0630
Mailing Address - Country:US
Mailing Address - Phone:803-364-4852
Mailing Address - Fax:
Practice Address - Street 1:600 N WHEELER AVE
Practice Address - Street 2:
Practice Address - City:PROSPERITY
Practice Address - State:SC
Practice Address - Zip Code:29127-9332
Practice Address - Country:US
Practice Address - Phone:803-364-4852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPA1709363AM0700X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA78649223Medicare PIN