Provider Demographics
NPI:1679215628
Name:GASTON, MIKELLE (APRN)
Entity Type:Individual
Prefix:
First Name:MIKELLE
Middle Name:
Last Name:GASTON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 SANDY LN
Mailing Address - Street 2:
Mailing Address - City:CAYCE
Mailing Address - State:SC
Mailing Address - Zip Code:29033-2718
Mailing Address - Country:US
Mailing Address - Phone:803-237-6143
Mailing Address - Fax:
Practice Address - Street 1:114 SANDY LN
Practice Address - Street 2:
Practice Address - City:CAYCE
Practice Address - State:SC
Practice Address - Zip Code:29033-2718
Practice Address - Country:US
Practice Address - Phone:803-237-6143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23888363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily