Healthcare Provider Details

I. General information

NPI: 1871918375
Provider Name (Legal Business Name): KYLEE NICOLE SACKSTEDER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2014
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

937 RIVERWALK PKWY
ROCK HILL SC
29730-0178
US

IV. Provider business mailing address

937 RIVERWALK PKWY
ROCK HILL SC
29730-0178
US

V. Phone/Fax

Practice location:
  • Phone: 740-566-4621
  • Fax: 740-566-4622
Mailing address:
  • Phone: 740-566-4621
  • Fax: 740-566-4622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number201702355
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: