Provider Demographics
NPI:1689346611
Name:SALLEY, CAITLYN RISLEY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:CAITLYN
Middle Name:RISLEY
Last Name:SALLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CAITLYN
Other - Middle Name:JOAN
Other - Last Name:RISLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:888-472-0043
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:1033 SAINT ANDREWS BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-7156
Practice Address - Country:US
Practice Address - Phone:843-723-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA363A00000X
SC4835363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant