Provider Demographics
NPI:1285296988
Name:DEMICHELE, KIMBERLY SUZANNE (LPN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUZANNE
Last Name:DEMICHELE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1962 OAK TREE LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-9413
Mailing Address - Country:US
Mailing Address - Phone:843-607-7138
Mailing Address - Fax:
Practice Address - Street 1:721 WAPPOO RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5861
Practice Address - Country:US
Practice Address - Phone:843-813-7703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC44320164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1861678534Medicaid