Basic Information
Provider Information | |||||||||
NPI: | 1700382660 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ALINE | ||||||||
FirstName: | AIMEE | ||||||||
MiddleName: | HEATHER | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSN, FNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 743904 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303743904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8032967320 | ||||||||
FaxNumber: | 8032967330 | ||||||||
Practice Location | |||||||||
Address1: | 3 RICHLAND MEDICAL PARK DR STE 310 | ||||||||
Address2: |   | ||||||||
City: | COLUMBIA | ||||||||
State: | SC | ||||||||
PostalCode: | 292036862 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8034348323 | ||||||||
FaxNumber: | 8034348326 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2018 | ||||||||
LastUpdateDate: | 09/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0205244 | SC | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 363LF0000X | 21698 | SC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | NP5739 | 05 | SC |   | MEDICAID |