Provider Demographics
NPI:1295374692
Name:WETZEL, MANDA RAE (FNP)
Entity Type:Individual
Prefix:
First Name:MANDA
Middle Name:RAE
Last Name:WETZEL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MANDA
Other - Middle Name:RAE
Other - Last Name:BESHORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:380 2ND AVE S
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-8153
Mailing Address - Country:US
Mailing Address - Phone:717-818-9912
Mailing Address - Fax:
Practice Address - Street 1:809 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4607
Practice Address - Country:US
Practice Address - Phone:843-692-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23454363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily