Provider Demographics
NPI:1639332513
Name:GRANT-SPENCE, CRISTAL SUZANNE (DPM)
Entity Type:Individual
Prefix:DR
First Name:CRISTAL
Middle Name:SUZANNE
Last Name:GRANT-SPENCE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:CRISTAL
Other - Middle Name:SUZANNE
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:9121 NW 17TH ST
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33322-4338
Mailing Address - Country:US
Mailing Address - Phone:954-304-0121
Mailing Address - Fax:
Practice Address - Street 1:9121 NW 17TH ST
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33322-4338
Practice Address - Country:US
Practice Address - Phone:954-304-0121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY65 006287213ES0103X
FLPO 3361213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBE916ZOtherMEDICARE PTAN
FLEV067AMedicare PIN