Provider Demographics
NPI:1063845808
Name:WALSTON, AMBER LEE (NP)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:LEE
Last Name:WALSTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:645-225-6038
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR STE A350
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3547
Practice Address - Country:US
Practice Address - Phone:864-454-5110
Practice Address - Fax:864-241-9206
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18429363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP2558Medicaid
SCSC55677951Medicare PIN