Provider Demographics
NPI:1386378917
Name:WILKERSON, SHAWNTOYA
Entity type:Individual
Prefix:
First Name:SHAWNTOYA
Middle Name:
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556-3235
Mailing Address - Country:US
Mailing Address - Phone:843-355-3621
Mailing Address - Fax:843-355-3624
Practice Address - Street 1:342 W MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGSTREE
Practice Address - State:SC
Practice Address - Zip Code:29556-3235
Practice Address - Country:US
Practice Address - Phone:843-355-3621
Practice Address - Fax:843-355-3624
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC43195164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse