Provider Demographics
NPI:1922438357
Name:GRANNIS, MARYBETH (CNM)
Entity Type:Individual
Prefix:
First Name:MARYBETH
Middle Name:
Last Name:GRANNIS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 KING ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-2716
Mailing Address - Country:US
Mailing Address - Phone:703-549-5070
Mailing Address - Fax:703-549-4821
Practice Address - Street 1:1501 KING ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2716
Practice Address - Country:US
Practice Address - Phone:703-549-5070
Practice Address - Fax:703-549-4821
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-21
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024171330363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology