MEDICARE: MISS IRENE DOROTHY HALLOCK FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	F2018	SC

General Provider Information

NPI Number	:	1386699866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS IRENE DOROTHY HALLOCK FNP

Provider Business Mailing Address
First Line	:	2102 CROMLEY CIR STE B
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-3187
Country	:	US
Telephone Number	:	843-839-5286
Fax Number	:	843-353-2528

Provider Business Practice Location Address
First Line	:	2102 CROMLEY CIR STE B
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-3187
Country	:	US
Telephone Number	:	843-839-2865
Fax Number	:	843-353-2528

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	04/27/2023

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