Provider Demographics
NPI:1932751559
Name:RIDDICK, CAROLINE GRAY (MSN, FNP-C)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:GRAY
Last Name:RIDDICK
Suffix:
Gender:F
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 EDMONDSTON CT
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-3161
Mailing Address - Country:US
Mailing Address - Phone:864-561-7835
Mailing Address - Fax:
Practice Address - Street 1:527 MILLS AVE # 201A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5602
Practice Address - Country:US
Practice Address - Phone:864-603-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-13
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22662363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner