Provider Demographics
NPI:1568969079
Name:RALLEY, TASHA LEE (FNP-C)
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:LEE
Last Name:RALLEY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-777-7401
Mailing Address - Fax:843-777-7476
Practice Address - Street 1:101 S RAVENEL ST STE 270
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2624
Practice Address - Country:US
Practice Address - Phone:843-777-7020
Practice Address - Fax:843-664-9545
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21690363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily