Provider Demographics
NPI:1043679129
Name:GRANTHAM, STEPHEN (RN)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:GRANTHAM
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 RIDGEWOOD LOOP
Mailing Address - Street 2:
Mailing Address - City:VILONIA
Mailing Address - State:AR
Mailing Address - Zip Code:72173-8058
Mailing Address - Country:US
Mailing Address - Phone:501-912-6884
Mailing Address - Fax:
Practice Address - Street 1:39 RIDGEWOOD LOOP
Practice Address - Street 2:
Practice Address - City:VILONIA
Practice Address - State:AR
Practice Address - Zip Code:72173-8058
Practice Address - Country:US
Practice Address - Phone:501-912-6884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR095593163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse