Provider Demographics
NPI:1437852985
Name:GRANT, MIKAYLA ALICE
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:ALICE
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 1:45 N MILPITAS BLVD
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-4402
Mailing Address - Country:US
Mailing Address - Phone:480-946-6424
Mailing Address - Fax:
Practice Address - Street 1:45 N MILPITAS BLVD
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-4402
Practice Address - Country:US
Practice Address - Phone:480-946-6424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-23
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95245076163W00000X
CA95024930363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse