Healthcare Provider Details

I. General information

NPI: 1538541792
Provider Name (Legal Business Name): ALICIA DAWN WOMACK NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 MEDICAL CENTER DR
GAFFNEY SC
29340-4823
US

IV. Provider business mailing address

PO BOX 743070
ATLANTA GA
30374-3070
US

V. Phone/Fax

Practice location:
  • Phone: 864-487-7186
  • Fax: 864-487-7246
Mailing address:
  • Phone: 864-560-4304
  • Fax: 864-560-4413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19572
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: