Provider Demographics
NPI:1497106017
Name:VAHLE, MARY NERISSA (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:NERISSA
Last Name:VAHLE
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 1:1204 E CHEVES ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2710
Mailing Address - Country:US
Mailing Address - Phone:843-673-0122
Mailing Address - Fax:843-661-6400
Practice Address - Street 1:1204 E CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2710
Practice Address - Country:US
Practice Address - Phone:843-673-0122
Practice Address - Fax:843-661-6400
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041400926163W00000X
IL209014924363LF0000X
SC22829363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
F400333339Medicare PIN