Provider Demographics
NPI:1053378901
Name:ROSS-PURDIE, LAVON M (FNP)
Entity type:Individual
Prefix:MS
First Name:LAVON
Middle Name:M
Last Name:ROSS-PURDIE
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:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-545-5017
Mailing Address - Fax:803-255-3451
Practice Address - Street 1:1 RICHLAND MEDICAL PARK DR STE 300
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-545-5350
Practice Address - Fax:803-545-5353
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN1907363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0769Medicaid
AA02781955Medicare ID - Type Unspecified
SCAA02782603Medicare PIN
SCNP0769Medicaid
SCAA02781955Medicare PIN