Provider Demographics
NPI:1437487071
Name:GRANDERSON, NICHOLAS JAMES (LPN)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JAMES
Last Name:GRANDERSON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 WHITE PLAINS RD STE 510
Mailing Address - Street 2:
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-5152
Mailing Address - Country:US
Mailing Address - Phone:914-345-5900
Mailing Address - Fax:
Practice Address - Street 1:300 HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-1810
Practice Address - Country:US
Practice Address - Phone:914-345-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-19
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY289884164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse