Provider Demographics
NPI:1093425209
Name:GRANT, SHAWNTA
Entity Type:Individual
Prefix:
First Name:SHAWNTA
Middle Name:
Last Name:GRANT
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 1:1253 DICKSON AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:HANAHAN
Mailing Address - State:SC
Mailing Address - Zip Code:29410-2853
Mailing Address - Country:US
Mailing Address - Phone:843-901-1242
Mailing Address - Fax:
Practice Address - Street 1:1253 DICKSON AVE STE 105
Practice Address - Street 2:
Practice Address - City:HANAHAN
Practice Address - State:SC
Practice Address - Zip Code:29410-2853
Practice Address - Country:US
Practice Address - Phone:843-901-1242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-1756251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCIHCP-1756OtherDHEC HOME CARE LICENSE NUMBER