=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912344201
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRACE LOTT NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2013
-----------------------------------------------------
Last Update Date | 11/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 HAWTHORNE PARK CT
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29615-3194
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-036-5600
-----------------------------------------------------
Fax | 864-603-5601
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 BROCKMAN MCCLIMON RD
-----------------------------------------------------
City | GREER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29651-6608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-989-1432
-----------------------------------------------------
Fax | 864-989-1338
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 18007
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------