Provider Demographics
NPI:1508868266
Name:GANTT, TONJA A (N P)
Entity Type:Individual
Prefix:MRS
First Name:TONJA
Middle Name:A
Last Name:GANTT
Suffix:
Gender:F
Credentials:N P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 OLD CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-9406
Mailing Address - Country:US
Mailing Address - Phone:803-359-2273
Mailing Address - Fax:
Practice Address - Street 1:716 OLD CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9406
Practice Address - Country:US
Practice Address - Phone:803-359-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN2136363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0889Medicaid
AA07925665Medicare ID - Type Unspecified
SCNP0889Medicaid