Provider Demographics
NPI:1164055950
Name:GRANTHAM, KARIN ELAINE (APRN)
Entity Type:Individual
Prefix:
First Name:KARIN
Middle Name:ELAINE
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16144 ROCKY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BULLARD
Mailing Address - State:TX
Mailing Address - Zip Code:75757-9733
Mailing Address - Country:US
Mailing Address - Phone:903-747-2205
Mailing Address - Fax:
Practice Address - Street 1:409 W FERGUSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-5632
Practice Address - Country:US
Practice Address - Phone:903-596-8353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-20
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX533441163W00000X
TX1044084364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty