Provider Demographics
NPI:1417360413
Name:VIRTUE, GRANT WILLIAM
Entity Type:Individual
Prefix:MR
First Name:GRANT
Middle Name:WILLIAM
Last Name:VIRTUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15504 NE 2ND ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-3340
Mailing Address - Country:US
Mailing Address - Phone:407-970-4450
Mailing Address - Fax:
Practice Address - Street 1:15504 NE 2ND ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-3340
Practice Address - Country:US
Practice Address - Phone:407-970-4450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONA.00755317376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide