Healthcare Provider Details

I. General information

NPI: 1760314793
Provider Name (Legal Business Name): IYONA RICKERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 JONATHAN LUCAS ST
CHARLESTON SC
29425-1600
US

IV. Provider business mailing address

99 JONATHAN LUCAS ST
CHARLESTON SC
29425-1600
US

V. Phone/Fax

Practice location:
  • Phone: 803-543-0939
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number370708
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: