Provider Demographics
NPI:1194775866
Name:LYKES, WENDY L (APRN)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:L
Last Name:LYKES
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:710 RABON RD STE 203
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-8903
Practice Address - Country:US
Practice Address - Phone:803-274-6166
Practice Address - Fax:803-973-6640
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN1415363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0430Medicaid
SCFQC030Medicaid
WI421841Medicare ID - Type Unspecified
SC7131Medicare ID - Type UnspecifiedLOCAL
SCP20776Medicare UPIN
WI421832Medicare ID - Type Unspecified
SCFQC043Medicaid