Basic Information
Provider Information | |||||||||
NPI: | 1962479170 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLER DERAJTYS | ||||||||
FirstName: | K. PATRICIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DERAJTYS | ||||||||
OtherFirstName: | KATHLEEN | ||||||||
OtherMiddleName: | PATRICIA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1278 N LAFAYETTE DR | ||||||||
Address2: |   | ||||||||
City: | SUMTER | ||||||||
State: | SC | ||||||||
PostalCode: | 291502964 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037744500 | ||||||||
FaxNumber: | 8037744641 | ||||||||
Practice Location | |||||||||
Address1: | 1278 N LAFAYETTE DRIVE | ||||||||
Address2: |   | ||||||||
City: | SUMTER | ||||||||
State: | SC | ||||||||
PostalCode: | 29150 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037744500 | ||||||||
FaxNumber: | 8037744641 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/07/2006 | ||||||||
LastUpdateDate: | 03/22/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 236 | SC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | NP0840 | 05 | SC |   | MEDICAID |