Provider Demographics
NPI:1811925142
Name:WORTH, MARY SUE (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SUE
Last Name:WORTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SUE
Other - Last Name:RAAF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 485
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-0485
Mailing Address - Country:US
Mailing Address - Phone:803-898-8405
Mailing Address - Fax:
Practice Address - Street 1:130 HIGHWAY 252
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5054
Practice Address - Country:US
Practice Address - Phone:803-898-8405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR61670363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0716Medicaid
SCNP0716Medicaid
SCP991143361Medicare PIN