Healthcare Provider Details

I. General information

NPI: 1932059888
Provider Name (Legal Business Name): TENIKQUA FULLWOOD-MAPLE PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2026
Last Update Date: 01/30/2026
Certification Date: 01/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1278 N LAFAYETTE DR
SUMTER SC
29150-2964
US

IV. Provider business mailing address

2733 SANDHILL DR
SUMTER SC
29154-5316
US

V. Phone/Fax

Practice location:
  • Phone: 803-774-4500
  • Fax:
Mailing address:
  • Phone: 803-774-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number31415
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: