Basic Information
| Provider Information | |||||||||
| NPI: | 1023600590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALBOURNE | ||||||||
| FirstName: | CHLOE | ||||||||
| MiddleName: | LEORA JEAN LUKE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3700 HIGHWAY 554 | ||||||||
| Address2: | |||||||||
| City: | LORIS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295696528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434215888 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | MUSC 2829 E HIGHWAY 76 MULLINS | ||||||||
| Address2: | |||||||||
| City: | MULLINS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295742957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8434312000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2021 | ||||||||
| LastUpdateDate: | 08/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.