Healthcare Provider Details

I. General information

NPI: 1912665829
Provider Name (Legal Business Name): WAKEETHA RENEE LEGARE-BROWN HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2021
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4848 MAYBANK HWY
WADMALAW ISLAND SC
29487-7081
US

IV. Provider business mailing address

4848 MAYBANK HWY
WADMALAW ISLAND SC
29487-7081
US

V. Phone/Fax

Practice location:
  • Phone: 843-425-6416
  • Fax:
Mailing address:
  • Phone: 843-425-6416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number69137
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: