Healthcare Provider Details

I. General information

NPI: 1629683073
Provider Name (Legal Business Name): WANDA BYERS OXENDINE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2020
Last Update Date: 09/12/2020
Certification Date: 09/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MEDICAL CAMPUS DR NW STE 105
SUPPLY NC
28462-4094
US

IV. Provider business mailing address

147 PROFESSIONAL LN
PAWLEYS ISLAND SC
29585-7878
US

V. Phone/Fax

Practice location:
  • Phone: 843-839-2550
  • Fax:
Mailing address:
  • Phone: 843-314-5847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5013537
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: