Provider Demographics
NPI:1578137709
Name:GADDIST, KECIA (CNA)
Entity Type:Individual
Prefix:MRS
First Name:KECIA
Middle Name:
Last Name:GADDIST
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:JOHNS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29455-8833
Mailing Address - Country:US
Mailing Address - Phone:843-806-7177
Mailing Address - Fax:
Practice Address - Street 1:4660 RIVER RD
Practice Address - Street 2:
Practice Address - City:JOHNS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29455-8833
Practice Address - Country:US
Practice Address - Phone:843-806-7177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4100040419376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide