Healthcare Provider Details

I. General information

NPI: 1053000927
Provider Name (Legal Business Name): ALEXA-GAIL RUTH-ANN WOOLERY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 05/05/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 EDGEWATER CORPORATE PKWY
INDIAN LAND SC
29707-4514
US

IV. Provider business mailing address

1830 GINGERCAKE CIR APT 203
ROCK HILL SC
29732-7434
US

V. Phone/Fax

Practice location:
  • Phone: 803-548-7007
  • Fax:
Mailing address:
  • Phone: 803-389-1497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number27289
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: