Healthcare Provider Details

I. General information

NPI: 1174489983
Provider Name (Legal Business Name): REBECCA GAYLE WARREN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/25/2025
Last Update Date: 12/25/2025
Certification Date: 12/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 JOHNATHON LN
EASLEY SC
29640-6335
US

IV. Provider business mailing address

105 JOHNATHON LN
EASLEY SC
29640-6335
US

V. Phone/Fax

Practice location:
  • Phone: 270-505-2810
  • Fax:
Mailing address:
  • Phone: 270-505-2810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number31191A
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: