Basic Information
| Provider Information | |||||||||
| NPI: | 1093189011 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | KONTIA | ||||||||
| MiddleName: | JONTAE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 ROE RD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296117423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642952308 | ||||||||
| FaxNumber: | 8642952635 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 ROE RD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296117423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642952308 | ||||||||
| FaxNumber: | 8642952635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2015 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 5008188 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 20719 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1093189011 | 05 | NC | MEDICAID |