Healthcare Provider Details

I. General information

NPI: 1639151475
Provider Name (Legal Business Name): SHELLEY G. STEVENS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELLEY GRAINGER PA-C

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 SUNSET BLVD
WEST COLUMBIA SC
29169-4810
US

IV. Provider business mailing address

PO BOX 6069
WEST COLUMBIA SC
29171-6069
US

V. Phone/Fax

Practice location:
  • Phone: 803-791-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1051
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: