Provider Demographics
NPI:1073684577
Name:GRAINGER, WANDA W (FNP)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:W
Last Name:GRAINGER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-392-9222
Mailing Address - Fax:843-392-1445
Practice Address - Street 1:3109 CASEY ST
Practice Address - Street 2:SUITE A
Practice Address - City:LORIS
Practice Address - State:SC
Practice Address - Zip Code:29569-2807
Practice Address - Country:US
Practice Address - Phone:843-756-9292
Practice Address - Fax:843-756-9260
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0792Medicaid
SCAA58658552OtherMEDICARE PTAN