Provider Demographics
NPI:1114139581
Name:GRANT, MARY ELIZABETH (ARNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELIZABETH
Last Name:GRANT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 63RD ST S
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707-3125
Mailing Address - Country:US
Mailing Address - Phone:727-347-2914
Mailing Address - Fax:727-895-7225
Practice Address - Street 1:1120 63RD ST S
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:FL
Practice Address - Zip Code:33707-3125
Practice Address - Country:US
Practice Address - Phone:727-347-2914
Practice Address - Fax:727-895-7225
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-05
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1572502163WP0808X, 363LP0808X
OH019367363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL300887800Medicaid
FL764196600Medicaid