Provider Demographics
NPI:1295039501
Name:GRANT, JACQUELINE A (RN)
Entity Type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:A
Last Name:GRANT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:ANITA
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:223-55 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16937 144TH RD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-5929
Practice Address - Country:US
Practice Address - Phone:718-978-7221
Practice Address - Fax:718-978-0032
Is Sole Proprietor?:No
Enumeration Date:2010-12-29
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY556905-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse