Provider Demographics
NPI:1235385477
Name:GRANGER, SALLY JAYE (ARNP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:JAYE
Last Name:GRANGER
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:PO BOX 8500
Mailing Address - Street 2:LOCKBOX #7642
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-7642
Mailing Address - Country:US
Mailing Address - Phone:813-281-8115
Mailing Address - Fax:813-281-8656
Practice Address - Street 1:12502 USF PINE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9411
Practice Address - Country:US
Practice Address - Phone:813-975-7117
Practice Address - Fax:813-975-7129
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2053652363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000375000Medicaid
FL000375000Medicaid