Provider Demographics
NPI:1285171694
Name:GAILLARD, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:GAILLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 FARMERS MARKET RD
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:SC
Mailing Address - Zip Code:29477-8290
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:109 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-2673
Practice Address - Country:US
Practice Address - Phone:843-719-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-23
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20150163W00000X, 163WC1500X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health