Provider Demographics
NPI:1588211197
Name:WILES, JACQUELINE GABRIELLE (APRN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:GABRIELLE
Last Name:WILES
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BOOKER DR
Mailing Address - Street 2:
Mailing Address - City:WALHALLA
Mailing Address - State:SC
Mailing Address - Zip Code:29691-2278
Mailing Address - Country:US
Mailing Address - Phone:864-656-3076
Mailing Address - Fax:843-985-9562
Practice Address - Street 1:200 BOOKER DR
Practice Address - Street 2:
Practice Address - City:WALHALLA
Practice Address - State:SC
Practice Address - Zip Code:29691-2278
Practice Address - Country:US
Practice Address - Phone:864-656-3076
Practice Address - Fax:843-985-9562
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23172363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP6253Medicaid