Provider Demographics
NPI:1629891072
Name:WADE, KISTRICIA BREYANNA (CNA)
Entity type:Individual
Prefix:
First Name:KISTRICIA
Middle Name:BREYANNA
Last Name:WADE
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 CENTRAL PARK RD APT F10
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-2807
Mailing Address - Country:US
Mailing Address - Phone:843-925-2995
Mailing Address - Fax:
Practice Address - Street 1:1815 CENTRAL PARK RD APT F10
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-2807
Practice Address - Country:US
Practice Address - Phone:843-925-2995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC58996463747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant