Healthcare Provider Details

I. General information

NPI: 1821565334
Provider Name (Legal Business Name): GRACE WIELICKI COUCH FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2018
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 BROAD ST
SUMTER SC
29150-4167
US

IV. Provider business mailing address

101 OLD GEORGETOWN RD
MANNING SC
29102-2721
US

V. Phone/Fax

Practice location:
  • Phone: 803-773-5227
  • Fax:
Mailing address:
  • Phone: 803-460-5151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22307
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: