Provider Demographics
NPI:1114364213
Name:RUSH, CLYDIA PAUL
Entity type:Individual
Prefix:
First Name:CLYDIA
Middle Name:PAUL
Last Name:RUSH
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 1:114 HOOK AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-5228
Mailing Address - Country:US
Mailing Address - Phone:803-739-4075
Mailing Address - Fax:
Practice Address - Street 1:114 HOOK AVE
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-5228
Practice Address - Country:US
Practice Address - Phone:803-739-4075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19936164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC$$$$$$$$$Medicaid