Provider Demographics
NPI:1427371434
Name:GRANT, CYNTHIA A
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:A
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:PO BOX 277723
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7723
Mailing Address - Country:US
Mailing Address - Phone:864-560-4123
Mailing Address - Fax:864-560-4023
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-4123
Practice Address - Fax:864-560-4023
Is Sole Proprietor?:No
Enumeration Date:2010-03-04
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4204367500000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00905777OtherRAILROAD MEDICARE
SCAN2087Medicaid
SCAN2087Medicaid