Provider Demographics
NPI:1740495688
Name:BLACK, JANICE D (NP)
Entity type:Individual
Prefix:MRS
First Name:JANICE
Middle Name:D
Last Name:BLACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:JANICE
Other - Middle Name:
Other - Last Name:DAGGERHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:803-935-8292
Mailing Address - Fax:
Practice Address - Street 1:154 SALUDA POINTE DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7295
Practice Address - Country:US
Practice Address - Phone:803-785-3590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPRN 619363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC619OtherAPN.RX
SC45834OtherRN LICENSE