Provider Demographics
NPI:1518115401
Name:GRANDY, ELLEN STEWART (LPTA)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:STEWART
Last Name:GRANDY
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3907 CARATOKE HWY
Mailing Address - Street 2:SENTARA NURSING CENTER
Mailing Address - City:BARCO
Mailing Address - State:NC
Mailing Address - Zip Code:27917
Mailing Address - Country:US
Mailing Address - Phone:252-457-0521
Mailing Address - Fax:252-457-0540
Practice Address - Street 1:3907 CARATOKE HWY
Practice Address - Street 2:SENTARA NURSING CENTER
Practice Address - City:BARCO
Practice Address - State:NC
Practice Address - Zip Code:27917
Practice Address - Country:US
Practice Address - Phone:252-457-0521
Practice Address - Fax:252-457-0540
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1107225200000X
VA2306602470225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant