Provider Demographics
NPI:1659633840
Name:GRANDY, REBECCA (APN)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:
Last Name:GRANDY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8324 WHITEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-9313
Mailing Address - Country:US
Mailing Address - Phone:870-879-1924
Mailing Address - Fax:
Practice Address - Street 1:4720 DOLLARWAY RD
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71602-4126
Practice Address - Country:US
Practice Address - Phone:870-536-3279
Practice Address - Fax:870-536-3283
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03707363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily