Basic Information
| Provider Information | |||||||||
| NPI: | 1518954478 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | HEPPARD | ||||||||
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| Credential: | DNP | ||||||||
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| OtherLastName: | HEPPARD | ||||||||
| OtherFirstName: | LORI | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 124 MALLARD ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296014046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642411040 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2710 GLASGOW AVE | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197024736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3028348686 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2005 | ||||||||
| LastUpdateDate: | 08/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AC000116 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 22041 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | LG0000330 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.