Provider Demographics
NPI:1619423480
Name:GRANT, ELNORA WEATHERSPOON (FNP)
Entity Type:Individual
Prefix:
First Name:ELNORA
Middle Name:WEATHERSPOON
Last Name:GRANT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ELNORA
Other - Middle Name:WEATHERSPOON
Other - Last Name:JIMERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP
Mailing Address - Street 1:4805 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2933
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4805 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213
Practice Address - Country:US
Practice Address - Phone:503-215-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201809398NP-PP363L00000X
WAAP60903125207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine