MEDICARE: LAKISHA DANIELLE FLADGER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	29778	SC

General Provider Information

NPI Number	:	1306654215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKISHA DANIELLE FLADGER

Provider Business Mailing Address
First Line	:	3656 S IRBY ST STE A1068
Second Line	:
City	:	FLORENCE
State	:	SC
Zip	:	29505-5225
Country	:	US
Telephone Number	:	843-621-6760
Fax Number	:

Provider Business Practice Location Address
First Line	:	3656 S IRBY ST STE A1068
Second Line	:
City	:	FLORENCE
State	:	SC
Zip	:	29505-5225
Country	:	US
Telephone Number	:	843-621-6760
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/23/2024
Last Update Date	:	12/23/2024

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Directions to “ LAKISHA DANIELLE FLADGER ” Practice Location

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