MEDICARE: MRS. SARAH MANGLICMOT CAMPOS O'NEILL APRN

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	363LP2300X	Primary Care Nurse Practitioner	21323	SC
2	363LF0000X	Family Nurse Practitioner	21323	SC

General Provider Information

NPI Number	:	1528569712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SARAH MANGLICMOT CAMPOS O'NEILL APRN

Provider Business Mailing Address
First Line	:	2050 CORPORATE CENTRE DR STE 220
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-7428
Country	:	US
Telephone Number	:	843-945-3234
Fax Number	:

Provider Business Practice Location Address
First Line	:	2050 CORPORATE CENTRE DR STE 220
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-7428
Country	:	US
Telephone Number	:	843-945-3234
Fax Number	:

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

Provider Enumeration Date	:	02/23/2018
Last Update Date	:	01/31/2024

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