Provider Demographics
NPI:1528172384
Name:DANIELS, MARY G (FNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:G
Last Name:DANIELS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-2925
Mailing Address - Country:US
Mailing Address - Phone:803-433-6790
Mailing Address - Fax:803-433-6796
Practice Address - Street 1:139 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLANTA
Practice Address - State:SC
Practice Address - Zip Code:29114
Practice Address - Country:US
Practice Address - Phone:843-396-4619
Practice Address - Fax:843-396-4503
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN2415363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0238Medicaid
SCS681901849Medicare ID - Type Unspecified
SCS68190Medicare UPIN