=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821888546
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY NICHOLS LOLLIS PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2025
-----------------------------------------------------
Last Update Date | 10/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1033 SAINT ANDREWS BLVD
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29407-7156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-723-6111
-----------------------------------------------------
Fax | 843-727-2973
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 751649
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28275-1649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-472-0043
-----------------------------------------------------
Fax | 843-724-2440
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------