Healthcare Provider Details

I. General information

NPI: 1811660822
Provider Name (Legal Business Name): SHANDA RETTA MAE HOFMANN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANDA RETTA MAE GEARHART MILLER

II. Dates (important events)

Enumeration Date: 07/26/2021
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 COURTENAY DR
CHARLESTON SC
29425-2866
US

IV. Provider business mailing address

PO BOX 751461
CHARLOTTE NC
28275-1461
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-3355
  • Fax:
Mailing address:
  • Phone: 843-792-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9965
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number28260
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: