Provider Demographics
NPI:1679888747
Name:GRANT, REBECCA (LPN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 UPTOWN RD APT 17E
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1607
Mailing Address - Country:US
Mailing Address - Phone:607-319-4922
Mailing Address - Fax:
Practice Address - Street 1:2250 WEHRLE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14221-7034
Practice Address - Country:US
Practice Address - Phone:716-276-2123
Practice Address - Fax:716-276-2129
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY287434164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse