Provider Demographics
NPI:1619278694
Name:GRANT, EUGENIE (CNA/PERS ASST)
Entity Type:Individual
Prefix:MRS
First Name:EUGENIE
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:CNA/PERS ASST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3112 SW WATSON CT
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-6302
Mailing Address - Country:US
Mailing Address - Phone:772-344-3531
Mailing Address - Fax:
Practice Address - Street 1:3112 SW WATSON CT
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-6302
Practice Address - Country:US
Practice Address - Phone:772-344-3531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1232374U00000X
FL1289376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL685174696Medicaid