Basic Information
| Provider Information | |||||||||
| NPI: | 1548596042 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIFFITH | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | MSN, RN, GNP-BC, ACH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 DOUG WHITE DR STE 250 | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295724181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432361950 | ||||||||
| FaxNumber: | 8432361952 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 DOUG WHITE DR STE 250 | ||||||||
| Address2: | |||||||||
| City: | MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295724181 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432361950 | ||||||||
| FaxNumber: | 8432361952 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2009 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 17481 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 1548596042 | 01 | SC | PENDING | OTHER | NP1872 | 05 | SC | MEDICAID |