Provider Demographics
NPI:1003809708
Name:GRANILLO, CHERYL (CNP)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:GRANILLO
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:HATCH
Mailing Address - State:NM
Mailing Address - Zip Code:87937-0370
Mailing Address - Country:US
Mailing Address - Phone:575-267-3280
Mailing Address - Fax:575-267-1747
Practice Address - Street 1:125 CHAPARREL BLVD NW
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-8629
Practice Address - Country:US
Practice Address - Phone:575-546-4800
Practice Address - Fax:575-546-0685
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR53026363L00000X
NMCNP01279363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM53985788Medicaid
Q26715Medicare UPIN
NM53985788Medicaid