Provider Demographics
NPI:1598743551
Name:GRANVILLE, KATHRYN (NP)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:
Last Name:GRANVILLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 HOUSATONIC AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-4026
Mailing Address - Country:US
Mailing Address - Phone:203-579-6548
Mailing Address - Fax:203-579-3688
Practice Address - Street 1:60 HOUSATONIC AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-4026
Practice Address - Country:US
Practice Address - Phone:203-579-6548
Practice Address - Fax:203-579-3688
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001766363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001766OtherLICENSE
CT004235900Medicaid