Provider Demographics
NPI:1457626863
Name:GRANNY NANNIES
Entity Type:Organization
Organization Name:GRANNY NANNIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-731-2100
Mailing Address - Street 1:9471 BAYMEADOWS ROAD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7937
Mailing Address - Country:US
Mailing Address - Phone:904-731-2100
Mailing Address - Fax:904-731-2177
Practice Address - Street 1:9471 BAYMEADOWS RD
Practice Address - Street 2:SUITE 403
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7932
Practice Address - Country:US
Practice Address - Phone:904-731-2100
Practice Address - Fax:904-731-2177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30211078251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health