Healthcare Provider Details

I. General information

NPI: 1760254387
Provider Name (Legal Business Name): NICOLE MARIE PANTIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2023
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 WACCAMAW MEDICAL PARK DR
CONWAY SC
29526-8903
US

IV. Provider business mailing address

1200 5TH AVE N APT 1304
SURFSIDE BEACH SC
29575-5925
US

V. Phone/Fax

Practice location:
  • Phone: 843-347-4888
  • Fax:
Mailing address:
  • Phone: 845-645-1897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number712393
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: