Provider Demographics
NPI:1710485073
Name:GRANT, VENETREA LAWANDA
Entity Type:Individual
Prefix:
First Name:VENETREA
Middle Name:LAWANDA
Last Name:GRANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9165 OTIS AVE STE 222
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46216-2316
Mailing Address - Country:US
Mailing Address - Phone:317-331-7068
Mailing Address - Fax:317-723-3772
Practice Address - Street 1:9165 OTIS AVE STE 222
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46216-2316
Practice Address - Country:US
Practice Address - Phone:317-331-7068
Practice Address - Fax:317-723-3772
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-31
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1701406313747P1801X, 3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN813743408Medicaid
IN300009906Medicaid