Healthcare Provider Details

I. General information

NPI: 1649134248
Provider Name (Legal Business Name): SUKENA SOPHIA WILEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 WACCAMAW MEDICAL PARK DR
CONWAY SC
29526-8903
US

IV. Provider business mailing address

164 WACCAMAW MEDICAL PARK DR
CONWAY SC
29526-8903
US

V. Phone/Fax

Practice location:
  • Phone: 843-347-4888
  • Fax:
Mailing address:
  • Phone: 843-347-4888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number.285763
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: