Provider Demographics
NPI:1457486193
Name:GRANBERRY, CHARLA GAYLE (FNP)
Entity Type:Individual
Prefix:
First Name:CHARLA
Middle Name:GAYLE
Last Name:GRANBERRY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 W RALPH HALL PKWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-6658
Mailing Address - Country:US
Mailing Address - Phone:972-771-9081
Mailing Address - Fax:972-772-7102
Practice Address - Street 1:1005 W RALPH HALL PKWY
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-6658
Practice Address - Country:US
Practice Address - Phone:972-771-9081
Practice Address - Fax:972-772-7102
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX246073363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX246073OtherNURSE PRACTIONER