Provider Demographics
NPI:1356969737
Name:HUDGENS-WALLACE, SKYLAR BRYNN
Entity type:Individual
Prefix:
First Name:SKYLAR
Middle Name:BRYNN
Last Name:HUDGENS-WALLACE
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 1:208 AMELIA OAKS WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-1753
Mailing Address - Country:US
Mailing Address - Phone:678-832-9239
Mailing Address - Fax:
Practice Address - Street 1:208 AMELIA OAKS WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1753
Practice Address - Country:US
Practice Address - Phone:678-832-9239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-11
Last Update Date:2020-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer