Healthcare Provider Details

I. General information

NPI: 1730044975
Provider Name (Legal Business Name): ANNA MARIE MACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 LAKE FOREST DR
FORT MILL SC
29708-8525
US

IV. Provider business mailing address

2100 LAKE FOREST DR
FORT MILL SC
29708-8525
US

V. Phone/Fax

Practice location:
  • Phone: 980-229-2125
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-16036
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: