Provider Demographics
NPI:1194544692
Name:ANDERSON, GRACE REBECCA (RN)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:REBECCA
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3685 RIVERS AVE RM 1D49
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-8057
Mailing Address - Country:US
Mailing Address - Phone:854-202-3599
Mailing Address - Fax:
Practice Address - Street 1:3685 RIVERS AVE RM 1D49
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-8057
Practice Address - Country:US
Practice Address - Phone:854-202-3599
Practice Address - Fax:843-953-1276
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC278962163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse