Basic Information
| Provider Information | |||||||||
| NPI: | 1609498849 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHARP | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | WILSON | ||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | STACEY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3 SAINT FRANCIS DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296013972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642338063 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3 SAINT FRANCIS DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296013971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642338063 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2020 | ||||||||
| LastUpdateDate: | 06/09/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 24376 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.