Provider Demographics
NPI:1568503019
Name:BOUKNIGHT, GAYLA DENISE
Entity Type:Individual
Prefix:MS
First Name:GAYLA
Middle Name:DENISE
Last Name:BOUKNIGHT
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 1:8213 SPRING FLOWER RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-5640
Mailing Address - Country:US
Mailing Address - Phone:803-419-6781
Mailing Address - Fax:
Practice Address - Street 1:8213 SPRING FLOWER RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-5640
Practice Address - Country:US
Practice Address - Phone:803-419-6781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCV04797251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCV04797Medicaid