Provider Demographics
NPI:1891831582
Name:GRANT, MARY LOUISE (NP-F)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:GRANT
Suffix:
Gender:F
Credentials:NP-F
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55585 29 PALMS HWY
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-2505
Mailing Address - Country:US
Mailing Address - Phone:760-228-3366
Mailing Address - Fax:760-228-3369
Practice Address - Street 1:55585 29 PALMS HWY
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-2505
Practice Address - Country:US
Practice Address - Phone:760-228-3366
Practice Address - Fax:760-228-3369
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13944363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA450731OtherRN LICENSE #
CA13944OtherNP LICENSE #