Healthcare Provider Details

I. General information

NPI: 1033029749
Provider Name (Legal Business Name): DICKERSON WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 S LAKE DR BOX 84432
LEXINGTON SC
29073-9760
US

IV. Provider business mailing address

1830 S LAKE DR BOX 84432
LEXINGTON SC
29073-9760
US

V. Phone/Fax

Practice location:
  • Phone: 803-477-4745
  • Fax: 843-258-4600
Mailing address:
  • Phone: 803-477-4745
  • Fax: 843-258-4600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. CHRISTINA JOCKLENE EDWARDS
Title or Position: NURSE PRACTITIONER/OWNER
Credential: AGPCNP-C
Phone: 803-477-4745