Provider Demographics
NPI:1992435754
Name:GROSSNICKLE, MERRITT HEADDEN (MD)
Entity type:Individual
Prefix:DR
First Name:MERRITT
Middle Name:HEADDEN
Last Name:GROSSNICKLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MERRITT
Other - Middle Name:LEE
Other - Last Name:HEADDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:169 ASHLEY AVENUE
Mailing Address - Street 2:ROOM 202 MAIN HOSPITAL MSC333
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 MCCLENNAN BANKS DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1164
Practice Address - Country:US
Practice Address - Phone:843-330-9824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC88204208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics