Basic Information
| Provider Information | |||||||||
| NPI: | 1013217850 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GROOME | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | AGNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976328 | ||||||||
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| Practice Location | |||||||||
| Address1: | 255 ENTERPRISE BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296156300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644548120 | ||||||||
| FaxNumber: | 8644548125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2010 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 19644 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP2300X | 19644 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | NP3381 | 05 | SC | MEDICAID |