Healthcare Provider Details

I. General information

NPI: 1790368421
Provider Name (Legal Business Name): AYLA VANSICKLE CNIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2021
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 SUNSET BLVD # 203
WEST COLUMBIA SC
29169-5914
US

IV. Provider business mailing address

1304 SUNSET BLVD # 203
WEST COLUMBIA SC
29169-5914
US

V. Phone/Fax

Practice location:
  • Phone: 888-851-3677
  • Fax:
Mailing address:
  • Phone: 888-851-3677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number4590
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: