Provider Demographics
NPI:1861469488
Name:MCKISSICK, AMY (NP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:MCKISSICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 SUMMERVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-1927
Mailing Address - Country:US
Mailing Address - Phone:803-240-2847
Mailing Address - Fax:
Practice Address - Street 1:1122 LADY ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3218
Practice Address - Country:US
Practice Address - Phone:803-240-2847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3057363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOTH000Medicare UPIN