Provider Demographics
NPI:1821850108
Name:PENN, KISHA BEACH
Entity Type:Individual
Prefix:PROF
First Name:KISHA
Middle Name:BEACH
Last Name:PENN
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 1:1427 PINETHICKET DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-8661
Mailing Address - Country:US
Mailing Address - Phone:843-343-2432
Mailing Address - Fax:
Practice Address - Street 1:100 CALLEN BLVD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-2807
Practice Address - Country:US
Practice Address - Phone:843-343-2432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC81496163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care