Provider Demographics
NPI:1215105085
Name:DORTENZO, MARY REGINA (RN-ANP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:REGINA
Last Name:DORTENZO
Suffix:
Gender:F
Credentials:RN-ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 MCSWAIN DR
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-4825
Mailing Address - Country:US
Mailing Address - Phone:803-767-4465
Mailing Address - Fax:803-767-4120
Practice Address - Street 1:176 MCSWAIN DR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4825
Practice Address - Country:US
Practice Address - Phone:803-767-4465
Practice Address - Fax:803-767-4120
Is Sole Proprietor?:No
Enumeration Date:2008-02-14
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4097363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1564Medicaid