Healthcare Provider Details

I. General information

NPI: 1003967860
Provider Name (Legal Business Name): ELAINE AMELLA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 JONATHAN LUCAS ST ROOM 410
CHARLESTON SC
29425-8900
US

IV. Provider business mailing address

1545 LANDINGS RUN
MT PLEASANT SC
29464-7716
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-4627
  • Fax:
Mailing address:
  • Phone: 843-792-4627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License NumberR 76317
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: