Healthcare Provider Details

I. General information

NPI: 1285171694
Provider Name (Legal Business Name): STACY GAILLARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2017
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 W MAIN ST
MONCKS CORNER SC
29461-2673
US

IV. Provider business mailing address

411 FARMERS MARKET RD
SAINT GEORGE SC
29477-8290
US

V. Phone/Fax

Practice location:
  • Phone: 843-719-4600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number20150
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number20150
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number20150
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: