Provider Demographics
NPI:1568194694
Name:DICKEY, KENISHA MELISSA
Entity Type:Individual
Prefix:
First Name:KENISHA
Middle Name:MELISSA
Last Name:DICKEY
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 1:20 E LIBERTY ST # 1-C
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-5237
Mailing Address - Country:US
Mailing Address - Phone:803-236-0139
Mailing Address - Fax:
Practice Address - Street 1:20 E LIBERTY ST # 1-C
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-5237
Practice Address - Country:US
Practice Address - Phone:803-236-0139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-1471251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC871183504OtherAGENCY