Provider Demographics
NPI:1093407603
Name:GAILLARD, MIRANDA TAYLOR (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:TAYLOR
Last Name:GAILLARD
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-2543
Mailing Address - Country:US
Mailing Address - Phone:864-373-7246
Mailing Address - Fax:
Practice Address - Street 1:129 S BROAD ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-2543
Practice Address - Country:US
Practice Address - Phone:864-373-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2023036845207Q00000X
SC27415363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine