Provider Demographics
NPI:1912665829
Name:LEGARE-BROWN, WAKEETHA RENEE (HAIR LOSS SPECIALIST)
Entity type:Individual
Prefix:MRS
First Name:WAKEETHA
Middle Name:RENEE
Last Name:LEGARE-BROWN
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4848 MAYBANK HWY
Mailing Address - Street 2:
Mailing Address - City:WADMALAW ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29487-7081
Mailing Address - Country:US
Mailing Address - Phone:843-425-6416
Mailing Address - Fax:
Practice Address - Street 1:4848 MAYBANK HWY
Practice Address - Street 2:
Practice Address - City:WADMALAW ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29487-7081
Practice Address - Country:US
Practice Address - Phone:843-425-6416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC69137224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty