Healthcare Provider Details

I. General information

NPI: 1578359014
Provider Name (Legal Business Name): MARILYN ANJUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2025
Last Update Date: 01/02/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 CHURCH ST STE A
CONWAY SC
29526-4422
US

IV. Provider business mailing address

300 SINGLETON RIDGE RD ATTN CREDENTIALING
CONWAY SC
29526-9142
US

V. Phone/Fax

Practice location:
  • Phone: 843-365-0295
  • Fax: 843-365-0354
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number30109
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: