Provider Demographics
NPI:1669086112
Name:FULLWOOD, DAHYOJENDAYI L
Entity type:Individual
Prefix:
First Name:DAHYOJENDAYI
Middle Name:L
Last Name:FULLWOOD
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 1:7620 RIVERS AVE
Mailing Address - Street 2:SUITE 370 PMB#155
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-5008
Mailing Address - Country:US
Mailing Address - Phone:866-491-1636
Mailing Address - Fax:843-737-4896
Practice Address - Street 1:3236 LANDMARK DR STE 121
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-8490
Practice Address - Country:US
Practice Address - Phone:866-491-1636
Practice Address - Fax:843-737-4896
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-1297372600000X, 373H00000X, 374U00000X, 376K00000X, 385H00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No372600000XNursing Service Related ProvidersAdult Companion
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide
No385H00000XRespite Care FacilityRespite Care