Healthcare Provider Details

I. General information

NPI: 1396389938
Provider Name (Legal Business Name): STACEY GLEN BANIS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 82ND PKWY
MYRTLE BEACH SC
29572-4607
US

IV. Provider business mailing address

809 82ND PKWY
MYRTLE BEACH SC
29572-4607
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number23374
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: