Provider Demographics
NPI:1306375829
Name:GILLILAND, MISTY BURNETT (FNP-C)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:BURNETT
Last Name:GILLILAND
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 MICHAELMAS AVE
Mailing Address - Street 2:
Mailing Address - City:CAYCE
Mailing Address - State:SC
Mailing Address - Zip Code:29033-3115
Mailing Address - Country:US
Mailing Address - Phone:803-463-0879
Mailing Address - Fax:
Practice Address - Street 1:CAROLINA HEALTH AND HEARING
Practice Address - Street 2:3681 LEAPHART RD STE A
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169
Practice Address - Country:US
Practice Address - Phone:803-520-8548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20805207Q00000X, 2083B0002X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20805OtherSC APRN LICENSE NUMBER
SCMB4338883OtherFEDERAL DEA NUMBER