Provider Demographics
NPI:1891453866
Name:NEELEY, GRANT MICHAEL
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:MICHAEL
Last Name:NEELEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2679 SABAL SPRINGS CIR APT E102
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-3124
Mailing Address - Country:US
Mailing Address - Phone:567-242-8991
Mailing Address - Fax:
Practice Address - Street 1:2679 SABAL SPRINGS CIR APT E102
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-3124
Practice Address - Country:US
Practice Address - Phone:567-242-8991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN406225363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty