Basic Information
| Provider Information | |||||||||
| NPI: | 1871932673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAMMON | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | WENDSCHLAG | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WENSCHLAG | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT STE 212 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976308 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 727 SE MAIN ST STE 320 | ||||||||
| Address2: | |||||||||
| City: | SIMPSONVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296813249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644546440 | ||||||||
| FaxNumber: | 8644546445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | LL35926 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 35926 | SC | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | LL35926 | SC | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 35926 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.