Provider Demographics
NPI:1497090476
Name:GRANT, THELMA B
Entity Type:Individual
Prefix:MRS
First Name:THELMA
Middle Name:B
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 1:1323 TANWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510
Mailing Address - Country:US
Mailing Address - Phone:516-546-8516
Mailing Address - Fax:516-546-0030
Practice Address - Street 1:1323 TANWOOD DR.
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510
Practice Address - Country:US
Practice Address - Phone:516-546-8516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000025176B00000X
NYF360293363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care