Healthcare Provider Details

I. General information

NPI: 1407679665
Provider Name (Legal Business Name): ERICA ANNE WALAJTYS REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. ERICA ANNE STILLWAGON

II. Dates (important events)

Enumeration Date: 11/06/2024
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E CHEVES ST
FLORENCE SC
29506-2617
US

IV. Provider business mailing address

555 E CHEVES ST
FLORENCE SC
29506-2617
US

V. Phone/Fax

Practice location:
  • Phone: 843-777-2000
  • Fax: 843-777-5465
Mailing address:
  • Phone: 843-777-2000
  • Fax: 843-777-5465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95020
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: