Provider Demographics
NPI:1437785979
Name:GRANGER, JODI E (AGNP)
Entity Type:Individual
Prefix:MS
First Name:JODI
Middle Name:E
Last Name:GRANGER
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-747-7236
Mailing Address - Fax:314-362-7769
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DEPT RADIATION ONCOLOGY, LL
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-747-7236
Practice Address - Fax:314-362-7769
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020004275363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420105836Medicaid