Provider Demographics
NPI:1578920047
Name:GRANT, TANISHA NICOLE
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:NICOLE
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 1:8115 SIMSBURY DR
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668-5146
Mailing Address - Country:US
Mailing Address - Phone:813-420-6873
Mailing Address - Fax:
Practice Address - Street 1:8115 SIMSBURY DR
Practice Address - Street 2:
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668-5146
Practice Address - Country:US
Practice Address - Phone:813-420-6873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide