Provider Demographics
NPI:1164938080
Name:GRANT, TANYA RENEE
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:RENEE
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 1:3536 SWEETWATER SPRINGS BLVD #D17
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977
Mailing Address - Country:US
Mailing Address - Phone:619-370-5429
Mailing Address - Fax:
Practice Address - Street 1:3536 SWEETWATER SPRINGS BLVD #D17
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977
Practice Address - Country:US
Practice Address - Phone:619-370-5429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN228680164X00000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health