Provider Demographics
NPI:1790350338
Name:DUBOSE, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DUBOSE
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 1:328 FLEET CIR
Mailing Address - Street 2:
Mailing Address - City:DARLINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29532-7677
Mailing Address - Country:US
Mailing Address - Phone:843-639-3419
Mailing Address - Fax:
Practice Address - Street 1:328 FLEET CIR
Practice Address - Street 2:
Practice Address - City:DARLINGTON
Practice Address - State:SC
Practice Address - Zip Code:29532-7677
Practice Address - Country:US
Practice Address - Phone:843-639-3419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC142632376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide