Provider Demographics
NPI:1407806953
Name:GRANT, LINDA L (NP)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:L
Last Name:GRANT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E MILLER RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-1252
Mailing Address - Country:US
Mailing Address - Phone:815-625-4790
Mailing Address - Fax:
Practice Address - Street 1:131 EAST JACKSON STREET
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:IL
Practice Address - Zip Code:61376
Practice Address - Country:US
Practice Address - Phone:815-379-2161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-000187363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00278896OtherRAILROAD MEDICARE
ILP00278896OtherRAILROAD MEDICARE
ILK23915Medicare ID - Type UnspecifiedSOUTHERN ILLINOIS
ILP23766Medicare UPIN