Provider Demographics
NPI:1154339695
Name:TETTERTON, STEPHANIE H (PA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:H
Last Name:TETTERTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-0520
Mailing Address - Country:US
Mailing Address - Phone:803-408-3277
Mailing Address - Fax:803-408-3282
Practice Address - Street 1:15 EXCHANGE DR
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-9198
Practice Address - Country:US
Practice Address - Phone:803-408-3277
Practice Address - Fax:803-408-3282
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC860207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC860Medicaid
SC860Medicaid