Healthcare Provider Details

I. General information

NPI: 1558711218
Provider Name (Legal Business Name): SHELLEY WILDS RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 BRIDGE VIEW DR STE 600
NORTH CHARLESTON SC
29405-8415
US

IV. Provider business mailing address

4050 BRIDGE VIEW DR STE 600
NORTH CHARLESTON SC
29405-8415
US

V. Phone/Fax

Practice location:
  • Phone: 843-953-0038
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number221572
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: