Healthcare Provider Details

I. General information

NPI: 1780221036
Provider Name (Legal Business Name): LYDIA STALLINGS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 STONY LANDING RD
MONCKS CORNER SC
29461-3967
US

IV. Provider business mailing address

403 STONY LANDING RD
MONCKS CORNER SC
29461-3967
US

V. Phone/Fax

Practice location:
  • Phone: 843-761-8282
  • Fax: 843-761-7308
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: