Provider Demographics
NPI:1568202869
Name:RICHARDSON, DAVEISHA JALYNN
Entity type:Individual
Prefix:
First Name:DAVEISHA
Middle Name:JALYNN
Last Name:RICHARDSON
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 1:5997 CAROLINA HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:DENMARK
Mailing Address - State:SC
Mailing Address - Zip Code:29042
Mailing Address - Country:US
Mailing Address - Phone:803-308-4716
Mailing Address - Fax:
Practice Address - Street 1:755 WHITMAN ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-6163
Practice Address - Country:US
Practice Address - Phone:803-534-7036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-27
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29811363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily