Provider Demographics
NPI:1114639283
Name:WINGATE, MIKAYLAH KIARA
Entity Type:Individual
Prefix:
First Name:MIKAYLAH
Middle Name:KIARA
Last Name:WINGATE
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 1:1150 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-0705
Mailing Address - Country:US
Mailing Address - Phone:843-383-2013
Mailing Address - Fax:843-383-8951
Practice Address - Street 1:1150 S 4TH ST
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-0705
Practice Address - Country:US
Practice Address - Phone:843-383-2013
Practice Address - Fax:843-383-8951
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1345156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician