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General NPI Number Information
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NPI Number | 1275130676
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Entity Type | Individual
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Provider Name | KEYONA TYESE WISE
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Gender | Female
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Dates
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Enumeration Date | 10/08/2020
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Last Update Date | 10/08/2020
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Provider Practice Location Address
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Address Line | 108 PINE RIDGE DR
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City | BLUFFTON
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State | SC
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Zip | 29910-6815
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Country | US
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Telephone | 843-338-8644
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Fax |
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Provider Business Mailing Address
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Address Line | 29 BROWN RD
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City | YEMASSEE
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State | SC
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Zip | 29945-7800
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Country | US
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Telephone | 843-338-8644
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MAS5571
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License Number State | SC
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