Healthcare Provider Details

I. General information

NPI: 1023452992
Provider Name (Legal Business Name): MS. ALICE M MAZZELLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 01/27/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9304 MEDICAL PLAZA DR STE D
CHARLESTON SC
29406-9143
US

IV. Provider business mailing address

9304 MEDICAL PLAZA DR STE D
CHARLESTON SC
29406-9143
US

V. Phone/Fax

Practice location:
  • Phone: 843-863-5600
  • Fax: 843-553-2123
Mailing address:
  • Phone: 843-863-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number22064
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF302704-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number22064
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: