Provider Demographics
NPI:1063025781
Name:GRANT, AUSTIN (LPN)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:GRANT
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 JOPLIN ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-2023
Mailing Address - Country:US
Mailing Address - Phone:618-603-6209
Mailing Address - Fax:
Practice Address - Street 1:205 JOPLIN ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-2023
Practice Address - Country:US
Practice Address - Phone:618-603-6209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.129163164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse