MEDICARE: ASHLEY GRACE MAIETTA

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	363LG0600X	Gerontology Nurse Practitioner	29298	SC

General Provider Information

NPI Number	:	1700610706
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY GRACE MAIETTA

Provider Business Mailing Address
First Line	:	207 CHARTWELL CT
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-7273
Country	:	US
Telephone Number	:	843-333-2816
Fax Number	:

Provider Business Practice Location Address
First Line	:	207 CHARTWELL CT
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-7273
Country	:	US
Telephone Number	:	843-333-2816
Fax Number	:

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

Provider Enumeration Date	:	08/30/2024
Last Update Date	:	08/30/2024

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Directions to “ ASHLEY GRACE MAIETTA ” Practice Location

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