Provider Demographics
NPI:1558198580
Name:CLYBURN, QUANITA MONTGOMERY
Entity type:Individual
Prefix:MRS
First Name:QUANITA
Middle Name:MONTGOMERY
Last Name:CLYBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1887 DUCKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-7402
Mailing Address - Country:US
Mailing Address - Phone:803-246-8419
Mailing Address - Fax:
Practice Address - Street 1:1356 FLAT CREEK RD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-7689
Practice Address - Country:US
Practice Address - Phone:803-246-8419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide