Provider Demographics
NPI:1871526335
Name:GWALTNEY, HOLLY (APRN)
Entity type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:
Last Name:GWALTNEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 CARLISLE ST
Mailing Address - Street 2:
Mailing Address - City:BAMBERG
Mailing Address - State:SC
Mailing Address - Zip Code:29003-1360
Mailing Address - Country:US
Mailing Address - Phone:803-707-1219
Mailing Address - Fax:
Practice Address - Street 1:3310 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-1468
Practice Address - Country:US
Practice Address - Phone:803-531-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1724363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5401724OtherLICENSE