Provider Demographics
NPI:1619295003
Name:GRANT, MARY L (RN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:L
Last Name:GRANT
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 1:912 KARL ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301
Mailing Address - Country:US
Mailing Address - Phone:920-432-1014
Mailing Address - Fax:
Practice Address - Street 1:912 KARL ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2225
Practice Address - Country:US
Practice Address - Phone:920-432-1014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9450730163W00000X, 163WH0200X, 163WH1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WH1000XNursing Service ProvidersRegistered NurseHospice