Healthcare Provider Details

I. General information

NPI: 1730507120
Provider Name (Legal Business Name): STACIE WALLING RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

932 HOLLY ST
HOLLY HILL SC
29059-2762
US

IV. Provider business mailing address

8423 OLD STATE ROAD
HOLLY HILL SC
29059
US

V. Phone/Fax

Practice location:
  • Phone: 803-496-3324
  • Fax: 803-496-9653
Mailing address:
  • Phone: 803-496-3324
  • Fax: 803-496-9653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number436478
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: