Provider Demographics
NPI:1790242980
Name:GRANT, BOBBIE NICOLE (CERTHAIRLOSS SPEC)
Entity Type:Individual
Prefix:
First Name:BOBBIE
Middle Name:NICOLE
Last Name:GRANT
Suffix:
Gender:F
Credentials:CERTHAIRLOSS SPEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2757 WHITE ACRES DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-3692
Mailing Address - Country:US
Mailing Address - Phone:408-508-0531
Mailing Address - Fax:
Practice Address - Street 1:2757 WHITE ACRES DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95148-3692
Practice Address - Country:US
Practice Address - Phone:408-508-0531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAKK5027761744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management