Healthcare Provider Details

I. General information

NPI: 1922360593
Provider Name (Legal Business Name): MARY ALICE LOLLIS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2012
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GAVOTTE LN
ANDERSON SC
29621-8205
US

IV. Provider business mailing address

100 GAVOTTE LN
ANDERSON SC
29621-8205
US

V. Phone/Fax

Practice location:
  • Phone: 864-261-7474
  • Fax: 864-261-8580
Mailing address:
  • Phone: 864-261-7474
  • Fax: 864-261-8580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number17911
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: