Provider Demographics
NPI:1093119836
Name:GRANT, WENDY
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 WHITNEY MESA DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-2080
Mailing Address - Country:US
Mailing Address - Phone:702-385-2020
Mailing Address - Fax:702-658-6608
Practice Address - Street 1:323 N MARYLAND PKWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89101-3130
Practice Address - Country:US
Practice Address - Phone:702-385-3330
Practice Address - Fax:702-207-7155
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1093119836Medicaid