Provider Demographics
NPI:1174911853
Name:ERICSSON, ANNA
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:ERICSSON
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 1:1536 GLEN ERIN DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7752
Mailing Address - Country:US
Mailing Address - Phone:843-475-0938
Mailing Address - Fax:
Practice Address - Street 1:1189 SWEETGRASS BASKET PKWY
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7422
Practice Address - Country:US
Practice Address - Phone:843-856-1210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-02
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC109500163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse