Provider Demographics
NPI:1609192194
Name:GRANVILLE, MARSHA ODESSA (RN)
Entity Type:Individual
Prefix:MISS
First Name:MARSHA
Middle Name:ODESSA
Last Name:GRANVILLE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14042 172ND ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-4624
Mailing Address - Country:US
Mailing Address - Phone:718-807-5474
Mailing Address - Fax:
Practice Address - Street 1:14042 172ND ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-4624
Practice Address - Country:US
Practice Address - Phone:718-807-5474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-09
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY613371-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse