Provider Demographics
NPI:1639384951
Name:GRANBERG, GENA DELL (FNP)
Entity Type:Individual
Prefix:
First Name:GENA
Middle Name:DELL
Last Name:GRANBERG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15914 NE 16TH CIR
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-4130
Mailing Address - Country:US
Mailing Address - Phone:360-944-6868
Mailing Address - Fax:
Practice Address - Street 1:9775 SE SUNNYSIDE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5739
Practice Address - Country:US
Practice Address - Phone:503-654-8417
Practice Address - Fax:503-654-8218
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily