Healthcare Provider Details

I. General information

NPI: 1093347973
Provider Name (Legal Business Name): DONNA SHILANE OUTLAW-THOMAS APRN-PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2020
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 PARK CREEK DR
GREENVILLE SC
29605-4270
US

IV. Provider business mailing address

PO BOX 405
SANTEE SC
29142-0405
US

V. Phone/Fax

Practice location:
  • Phone: 803-600-7106
  • Fax: 803-610-4197
Mailing address:
  • Phone: 803-600-7106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number100313
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number363LP0808X
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number24101
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: