Healthcare Provider Details

I. General information

NPI: 1902576929
Provider Name (Legal Business Name): TAYLOR NICOLE ADAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 CALHOUN ST
CHARLESTON SC
29401-1113
US

IV. Provider business mailing address

PO BOX 751649
CHARLOTTE NC
28275-1649
US

V. Phone/Fax

Practice location:
  • Phone: 843-720-8490
  • Fax: 843-727-3602
Mailing address:
  • Phone: 888-472-0043
  • Fax: 843-724-2440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6208
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11457
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: