Provider Demographics
NPI:1407337645
Name:GRANT, LARRISSA
Entity Type:Individual
Prefix:
First Name:LARRISSA
Middle Name:
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 1:7720 WOODLAND AVE APT G14
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-6815
Mailing Address - Country:US
Mailing Address - Phone:216-848-6245
Mailing Address - Fax:
Practice Address - Street 1:7720 WOODLAND AVE APT G14
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-6815
Practice Address - Country:US
Practice Address - Phone:216-356-7398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-26
Last Update Date:2018-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0255328Medicaid