Provider Demographics
NPI:1710996129
Name:WILKERSON, SHELLY C (NP)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:C
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:C
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2001 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-1018
Mailing Address - Country:US
Mailing Address - Phone:803-255-2655
Mailing Address - Fax:803-376-2870
Practice Address - Street 1:1330 HAILE ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-3002
Practice Address - Country:US
Practice Address - Phone:803-432-6771
Practice Address - Fax:803-376-2870
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC61322363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P17358Medicare UPIN