Healthcare Provider Details

I. General information

NPI: 1780457036
Provider Name (Legal Business Name): JACQUELINE OLA SHOWALTER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 EXECUTIVE PKWY STE 5
MONCKS CORNER SC
29461-3955
US

IV. Provider business mailing address

PO BOX 530062
ATLANTA GA
30353-0062
US

V. Phone/Fax

Practice location:
  • Phone: 843-761-2815
  • Fax:
Mailing address:
  • Phone: 843-572-7727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28026
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: