Provider Demographics
NPI:1962130617
Name:ANDERSON, HERMAINE LUCILLE
Entity type:Individual
Prefix:
First Name:HERMAINE
Middle Name:LUCILLE
Last Name:ANDERSON
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 1:4464 DEVINE ST STE M
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-3605
Mailing Address - Country:US
Mailing Address - Phone:803-979-9711
Mailing Address - Fax:
Practice Address - Street 1:1013 N KINGS STREET
Practice Address - Street 2:221F
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223
Practice Address - Country:US
Practice Address - Phone:803-979-9711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver