Basic Information
| Provider Information | |||||||||
| NPI: | 1619412079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHERRY-CASEY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NURSE PRACTITIONER | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHERRY-CASEY | ||||||||
| OtherFirstName: | M SUSAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2168 | ||||||||
| Address2: | |||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293042168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645604304 | ||||||||
| FaxNumber: | 8645604413 | ||||||||
| Practice Location | |||||||||
| Address1: | 322 W SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | UNION | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644298029 | ||||||||
| FaxNumber: | 8644293515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2016 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 20246 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | NP4455 | 05 | SC | MEDICAID | SCA149H888 | 01 | SC | MEDICARE PIN | OTHER |