Provider Demographics
NPI:1215978556
Name:GRUMELOT, LEEANNE JONES (PA)
Entity type:Individual
Prefix:
First Name:LEEANNE
Middle Name:JONES
Last Name:GRUMELOT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:200 PATEWOOD DR STE B480
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6327
Practice Address - Country:US
Practice Address - Phone:864-454-4570
Practice Address - Fax:864-454-4575
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC855363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC855OtherSC BOARD OF MEDICAL EXAMI
SC1525PAMedicaid
SC1525PAMedicaid