Individual
JACQUETTA RILEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1550 CAROLINA AVE, ORANGEBURG, SC 29115-4944
(803) 533-5489
Mailing address
1550 CAROLINA AVE, ORANGEBURG, SC 29115-4944
(803) 533-5489
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
P47848
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000
0000
—
01
—
0511SC
VACCINATING
SC
01
—
NONE
VACCINES
—
Enumeration date
01/15/2021
Last updated
01/15/2021
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