Healthcare Provider Details

I. General information

NPI: 1447797816
Provider Name (Legal Business Name): KRISTIE WADE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2017
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 CHESTER AVE
GREAT FALLS SC
29055-1104
US

IV. Provider business mailing address

859 DAISYWOOD LN
CHESTER SC
29706-8799
US

V. Phone/Fax

Practice location:
  • Phone: 803-482-2129
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number106459
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number24388
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: