Provider Demographics
NPI:1891460853
Name:GAYMON, KADEIDRE LA'TRELL
Entity Type:Individual
Prefix:
First Name:KADEIDRE
Middle Name:LA'TRELL
Last Name:GAYMON
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 1:286 LIBERTY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:SC
Mailing Address - Zip Code:29045-7905
Mailing Address - Country:US
Mailing Address - Phone:803-920-6625
Mailing Address - Fax:
Practice Address - Street 1:6439 GARNERS FERRY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1638
Practice Address - Country:US
Practice Address - Phone:803-920-6625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC249257163W00000X, 163WH0200X, 163WW0000X, 163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPVF908740801OtherBLUE CROSS BLUE SHIELD