Provider Demographics
NPI:1881485662
Name:SRP MEDICAL LLC
Entity type:Organization
Organization Name:SRP MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:R
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-AGACNP
Authorized Official - Phone:407-516-3756
Mailing Address - Street 1:742 SAINT ANDREWS BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7169
Mailing Address - Country:US
Mailing Address - Phone:407-516-3756
Mailing Address - Fax:
Practice Address - Street 1:1445 BLUEWATER WAY
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-7923
Practice Address - Country:US
Practice Address - Phone:407-516-3756
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty