Provider Demographics
NPI:1124113170
Name:AVERETTE, STEPHANIE EYVETTE (NP)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:EYVETTE
Last Name:AVERETTE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 FAISON DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-3210
Mailing Address - Country:US
Mailing Address - Phone:803-935-7140
Mailing Address - Fax:
Practice Address - Street 1:8301 FARROW RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-3245
Practice Address - Country:US
Practice Address - Phone:803-935-7879
Practice Address - Fax:803-935-5280
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC891363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1221Medicaid
SCAA32859090Medicare PIN
SCAA32853357Medicare PIN
SCNP1221Medicaid