Provider Demographics
NPI:1275130676
Name:WISE, KEYONA TYESE
Entity Type:Individual
Prefix:
First Name:KEYONA
Middle Name:TYESE
Last Name:WISE
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 1:29 BROWN RD
Mailing Address - Street 2:
Mailing Address - City:YEMASSEE
Mailing Address - State:SC
Mailing Address - Zip Code:29945-7800
Mailing Address - Country:US
Mailing Address - Phone:843-338-8644
Mailing Address - Fax:
Practice Address - Street 1:108 PINE RIDGE DR
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-6815
Practice Address - Country:US
Practice Address - Phone:843-338-8644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMAS5571225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist