Provider Demographics
NPI:1720202310
Name:GRANT, SHELLIE E (MD)
Entity Type:Individual
Prefix:
First Name:SHELLIE
Middle Name:E
Last Name:GRANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 PUTNAM PL
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-4019
Mailing Address - Country:US
Mailing Address - Phone:703-548-2342
Mailing Address - Fax:
Practice Address - Street 1:635 PUTNAM PL
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-4019
Practice Address - Country:US
Practice Address - Phone:703-548-2342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010350682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry