Provider Demographics
NPI:1265839229
Name:GRANVILLE, SAMANTHA NICOLE (LVN)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:NICOLE
Last Name:GRANVILLE
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:NICOLE
Other - Last Name:RIOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:87-136 KULALA PL
Mailing Address - Street 2:
Mailing Address - City:WAIANAE
Mailing Address - State:HI
Mailing Address - Zip Code:96792-3364
Mailing Address - Country:US
Mailing Address - Phone:760-646-6006
Mailing Address - Fax:
Practice Address - Street 1:87-136 KULALA PL
Practice Address - Street 2:
Practice Address - City:WAIANAE
Practice Address - State:HI
Practice Address - Zip Code:96792-3364
Practice Address - Country:US
Practice Address - Phone:760-646-6006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA252862164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse