Provider Demographics
NPI:1093189011
Name:GRANT, KONTIA JONTAE (NP)
Entity Type:Individual
Prefix:
First Name:KONTIA
Middle Name:JONTAE
Last Name:GRANT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 ROE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29611-7423
Mailing Address - Country:US
Mailing Address - Phone:864-295-2308
Mailing Address - Fax:864-295-2635
Practice Address - Street 1:15 ROE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-7423
Practice Address - Country:US
Practice Address - Phone:864-295-2308
Practice Address - Fax:864-295-2635
Is Sole Proprietor?:No
Enumeration Date:2015-11-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5008188363LF0000X
SC20719363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1093189011Medicaid