Healthcare Provider Details

I. General information

NPI: 1124982194
Provider Name (Legal Business Name): BAILEY ALYSE WAGNER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

100 HUNT RD
EASLEY SC
29642-9564
US

IV. Provider business mailing address

100 HUNT RD
EASLEY SC
29642-9564
US

V. Phone/Fax

Practice location:
  • Phone: 864-386-8923
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number254984
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: