MEDICARE: STACEY ELAM 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	29492	SC

General Provider Information

NPI Number	:	1992520092
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY ELAM FNP

Provider Business Mailing Address
First Line	:	27 GENTLE WINDS WAY
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29605-6447
Country	:	US
Telephone Number	:	864-361-5928
Fax Number	:

Provider Business Practice Location Address
First Line	:	27 GENTLE WINDS WAY
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29605-6447
Country	:	US
Telephone Number	:	864-361-5928
Fax Number	:

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

Provider Enumeration Date	:	11/22/2024
Last Update Date	:	11/22/2024

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