Healthcare Provider Details

I. General information

NPI: 1588575211
Provider Name (Legal Business Name): ALLISON MARIE WYETH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 82ND PKWY
MYRTLE BEACH SC
29572-4607
US

IV. Provider business mailing address

361 RIDGE POINT DR
CONWAY SC
29526-1217
US

V. Phone/Fax

Practice location:
  • Phone: 843-692-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number250642
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: