Healthcare Provider Details

I. General information

NPI: 1003395385
Provider Name (Legal Business Name): BLAIR GAULT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 THOMAS ST STE B
UNION SC
29379-2147
US

IV. Provider business mailing address

PO BOX 5158
SPARTANBURG SC
29304-5158
US

V. Phone/Fax

Practice location:
  • Phone: 864-582-2411
  • Fax:
Mailing address:
  • Phone: 864-582-2411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22024
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: