Provider Demographics
NPI:1740583350
Name:GRANDBERRY, NORMA P (IDMT)
Entity Type:Individual
Prefix:
First Name:NORMA
Middle Name:P
Last Name:GRANDBERRY
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 WESTCHESTER ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4638
Mailing Address - Country:US
Mailing Address - Phone:757-286-4505
Mailing Address - Fax:
Practice Address - Street 1:1501 WESTCHESTER ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4638
Practice Address - Country:US
Practice Address - Phone:757-286-4505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-21
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians