Provider Demographics
NPI:1982000949
Name:NIENABER, RACHEL M (PA)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:M
Last Name:NIENABER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:M
Other - Last Name:BUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:2145 HENRY TECKLENBURG DR STE 100
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5894
Practice Address - Country:US
Practice Address - Phone:843-556-0036
Practice Address - Fax:843-556-3871
Is Sole Proprietor?:No
Enumeration Date:2014-11-18
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3556363A00000X, 363A00000X
IN10001966A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4406PAMedicaid