| NPI | 1962092114 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GLORIA KATHERINE WILSON Authorized Official/Provider 843-801-0861 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner Adult Health |
| Additional Taxonomies | 363LC1500X Nurse Practitioner Community Health |
| 363LP0808X Nurse Practitioner Psychiatric/Mental Health | |
| Enumeration Date | 2021-01-21 |
| Last Update Date | 2023-09-14 |