Provider Demographics
NPI:1912651043
Name:GIBBONS-KEDNOCKER, MELISSA (HAS)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GIBBONS-KEDNOCKER
Suffix:
Gender:F
Credentials:HAS
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:GIBBONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 WELLNESS BLVD STE 112
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2873
Mailing Address - Country:US
Mailing Address - Phone:803-765-1919
Mailing Address - Fax:
Practice Address - Street 1:1 WELLNESS BLVD STE 112
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2873
Practice Address - Country:US
Practice Address - Phone:803-765-1919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-08
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0714237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist