Provider Demographics
NPI:1093970733
Name:GRANT, MARY (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9140 HIGHWAY 51 N
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-1233
Mailing Address - Country:US
Mailing Address - Phone:662-280-8222
Mailing Address - Fax:662-280-5541
Practice Address - Street 1:9140 HIGHWAY 51 N
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1233
Practice Address - Country:US
Practice Address - Phone:662-280-8222
Practice Address - Fax:662-280-5541
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MSR538515363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP76372Medicare UPIN