Healthcare Provider Details

I. General information

NPI: 1023413994
Provider Name (Legal Business Name): KATHLEEN GANTT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 BROOKDALE AVE
GREENVILLE SC
29607-2936
US

IV. Provider business mailing address

116 BROOKDALE AVE
GREENVILLE SC
29607-2936
US

V. Phone/Fax

Practice location:
  • Phone: 864-380-0456
  • Fax:
Mailing address:
  • Phone: 864-380-0456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number209651
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: