Healthcare Provider Details

I. General information

NPI: 1497106017
Provider Name (Legal Business Name): MARY NERISSA VAHLE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2016
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 E CHEVES ST
FLORENCE SC
29506-2710
US

IV. Provider business mailing address

1204 E CHEVES ST
FLORENCE SC
29506-2710
US

V. Phone/Fax

Practice location:
  • Phone: 843-673-0122
  • Fax: 843-661-6400
Mailing address:
  • Phone: 843-673-0122
  • Fax: 843-661-6400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041400926
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209014924
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22829
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: