Basic Information
Provider Information | |||||||||
NPI: | 1720594161 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLOYD | ||||||||
FirstName: | CASSIE | ||||||||
MiddleName: | MYLINDA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 SINGLETON RIDGE RD | ||||||||
Address2: | ATTENTION PATIENT ACCOUNTING | ||||||||
City: | CONWAY | ||||||||
State: | SC | ||||||||
PostalCode: | 295269142 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8432346827 | ||||||||
FaxNumber: | 8432346990 | ||||||||
Practice Location | |||||||||
Address1: | 2376 CYPRESS CIR STE 203 | ||||||||
Address2: |   | ||||||||
City: | CONWAY | ||||||||
State: | SC | ||||||||
PostalCode: | 295268994 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8433476038 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2017 | ||||||||
LastUpdateDate: | 06/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 21508 | SC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | NP4991 | 05 | SC |   | MEDICAID |