1073684577 NPI number — WANDA W GRAINGER FNP

Table of content: WANDA W GRAINGER FNP (NPI 1073684577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073684577 NPI number — WANDA W GRAINGER FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAINGER
Provider First Name:
WANDA
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073684577
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3239
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29502-3239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-392-9222
Provider Business Mailing Address Fax Number:
843-392-1445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3109 CASEY ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LORIS
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29569-2807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-756-9292
Provider Business Practice Location Address Fax Number:
843-756-9260
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  1033 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NP0792 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: AA58658552 . This is a "MEDICARE PTAN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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