Provider Demographics
NPI:1114522547
Name:MAPLE, KAWONNA NICOLE
Entity Type:Individual
Prefix:
First Name:KAWONNA
Middle Name:NICOLE
Last Name:MAPLE
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 1:223 MOCKINGBIRD DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:SC
Mailing Address - Zip Code:29039-9641
Mailing Address - Country:US
Mailing Address - Phone:803-662-9587
Mailing Address - Fax:
Practice Address - Street 1:109 JUSTINE CT
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:SC
Practice Address - Zip Code:29039-9196
Practice Address - Country:US
Practice Address - Phone:803-614-5088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor