Provider Demographics
NPI:1386696169
Name:DUBOSE, ANITA M (NP)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:M
Last Name:DUBOSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:ANITA
Other - Middle Name:M
Other - Last Name:STUCKEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1259
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29021-1259
Mailing Address - Country:US
Mailing Address - Phone:803-713-8350
Mailing Address - Fax:803-713-8433
Practice Address - Street 1:1344 HAILE ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-3076
Practice Address - Country:US
Practice Address - Phone:803-432-1996
Practice Address - Fax:803-424-2703
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAC52783363LA2100X
SC954363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC500021206OtherRAILROAD MEDICARE PIN
SCNP0204Medicaid
SCNP0204Medicaid
SCQ318065378Medicare PIN