Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LC1500X | Nurse Practitioner - Community Health | 14-60208-122 | KS |
Y | 363LF0000X | Nurse Practitioner - Family Medicine | RN213453 | GA |
NPI | 1124258967 |
---|---|
Provider Name | Jacqueline Mintz |
First Address | Columbia, SC 29229 |
Second Address | Shaw Afb, SC 29152 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2009 |
Last Update Date | 21/12/2011 |