Provider Demographics
NPI:1306323696
Name:GRANT, TEMICHA ROSHELL (RN)
Entity type:Individual
Prefix:
First Name:TEMICHA
Middle Name:ROSHELL
Last Name:GRANT
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 1:464 MCLAIN ST
Mailing Address - Street 2:
Mailing Address - City:PATRICK
Mailing Address - State:SC
Mailing Address - Zip Code:29584-5390
Mailing Address - Country:US
Mailing Address - Phone:843-910-0451
Mailing Address - Fax:843-498-7134
Practice Address - Street 1:464 MCLAIN ST
Practice Address - Street 2:
Practice Address - City:PATRICK
Practice Address - State:SC
Practice Address - Zip Code:29584-5390
Practice Address - Country:US
Practice Address - Phone:843-498-7134
Practice Address - Fax:843-498-7134
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC895993747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant