Healthcare Provider Details

I. General information

NPI: 1992729495
Provider Name (Legal Business Name): NANCY C GANNON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 BEE ST
CHARLESTON SC
29401-5703
US

IV. Provider business mailing address

1288 WICKS AVE
CHARLESTON SC
29412-5230
US

V. Phone/Fax

Practice location:
  • Phone: 843-789-7607
  • Fax: 843-805-5973
Mailing address:
  • Phone: 843-795-0547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: