Provider Demographics
NPI:1760594857
Name:GIST, DEMETRICE NICHOLE (RN)
Entity Type:Individual
Prefix:
First Name:DEMETRICE
Middle Name:NICHOLE
Last Name:GIST
Suffix:
Gender:F
Credentials:RN
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 929
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:SC
Mailing Address - Zip Code:29536
Mailing Address - Country:US
Mailing Address - Phone:843-774-3351
Mailing Address - Fax:843-774-2622
Practice Address - Street 1:1324 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536
Practice Address - Country:US
Practice Address - Phone:843-774-3851
Practice Address - Fax:843-774-2622
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC91850163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC405127Medicaid
SC405127Medicaid