Provider Demographics
NPI:1740602374
Name:GRANT, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
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 1:20 A L CORBETT CIRCLE
Mailing Address - Street 2:
Mailing Address - City:WAGENER
Mailing Address - State:SC
Mailing Address - Zip Code:29164
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 A L CORBETT CIRCLE
Practice Address - Street 2:
Practice Address - City:WAGENER
Practice Address - State:SC
Practice Address - Zip Code:29164
Practice Address - Country:US
Practice Address - Phone:803-564-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC97233163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC163WA200XMedicaid