Healthcare Provider Details

I. General information

NPI: 1376458208
Provider Name (Legal Business Name): AMY ELIZABETH WACHA BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1363 W DOGWOOD RD
LORIS SC
29569-8706
US

IV. Provider business mailing address

1363 W DOGWOOD RD
LORIS SC
29569-8706
US

V. Phone/Fax

Practice location:
  • Phone: 843-655-1523
  • Fax:
Mailing address:
  • Phone: 843-655-1523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number206533
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: