Provider Demographics
NPI:1609845478
Name:NEIL, GRANADA STEPHENS (MD)
Entity Type:Individual
Prefix:
First Name:GRANADA
Middle Name:STEPHENS
Last Name:NEIL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GRANADA
Other - Middle Name:SHALANE
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1400 MILLGATE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1338
Mailing Address - Country:US
Mailing Address - Phone:336-774-2194
Mailing Address - Fax:336-774-2195
Practice Address - Street 1:1400 MILLGATE DR
Practice Address - Street 2:SUITE D
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1338
Practice Address - Country:US
Practice Address - Phone:336-774-2194
Practice Address - Fax:336-774-2195
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200501450207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine