Healthcare Provider Details

I. General information

NPI: 1366367294
Provider Name (Legal Business Name): CARLA KENISHA HICKMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5164 SHALLOWFORD RD
DARLINGTON SC
29532-6945
US

IV. Provider business mailing address

5164 SHALLOWFORD RD
DARLINGTON SC
29532-6945
US

V. Phone/Fax

Practice location:
  • Phone: 910-921-5131
  • Fax: 910-921-5131
Mailing address:
  • Phone: 910-921-5131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number285776
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: