Provider Demographics
NPI:1821630492
Name:NESBITT, RENELL
Entity Type:Individual
Prefix:
First Name:RENELL
Middle Name:
Last Name:NESBITT
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 1:818 TOM HALL ST STE 110
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-2046
Mailing Address - Country:US
Mailing Address - Phone:318-308-2449
Mailing Address - Fax:
Practice Address - Street 1:818 TOM HALL ST STE 110
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-2046
Practice Address - Country:US
Practice Address - Phone:318-308-2449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101343329174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist