MEDICARE: KRISTIE WADE FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	106459	SC
2	363LF0000X	Family Nurse Practitioner	24388	SC

General Provider Information

NPI Number	:	1447797816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIE WADE FNP

Provider Business Mailing Address
First Line	:	859 DAISYWOOD LN
Second Line	:
City	:	CHESTER
State	:	SC
Zip	:	29706-8799
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	308 CHESTER AVE
Second Line	:
City	:	GREAT FALLS
State	:	SC
Zip	:	29055-1104
Country	:	US
Telephone Number	:	803-482-2129
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2017
Last Update Date	:	07/22/2021

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