Provider Demographics
NPI:1851322242
Name:GRANT, KRISTEN ELAINE (PAC)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ELAINE
Last Name:GRANT
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-2250
Mailing Address - Country:US
Mailing Address - Phone:330-633-8341
Mailing Address - Fax:330-633-8462
Practice Address - Street 1:145 WEST AVE
Practice Address - Street 2:
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-2250
Practice Address - Country:US
Practice Address - Phone:330-633-8341
Practice Address - Fax:330-633-8462
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1805363A00000X
OH50.2875363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9768939Medicaid
MAAP2405Medicare ID - Type Unspecified
MA9768939Medicaid