Provider Demographics
NPI:1437877222
Name:GRADY, LARQUIETTA
Entity Type:Individual
Prefix:
First Name:LARQUIETTA
Middle Name:
Last Name:GRADY
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 1:9307 S 51ST AVE UNIT 114
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-3906
Mailing Address - Country:US
Mailing Address - Phone:833-365-5331
Mailing Address - Fax:
Practice Address - Street 1:7412 S 37TH DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-6169
Practice Address - Country:US
Practice Address - Phone:833-365-5331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-17
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier