Provider Demographics
NPI:1922782069
Name:GRANZON, PHENNUELHY GRANT MIRASOL
Entity Type:Individual
Prefix:
First Name:PHENNUELHY
Middle Name:GRANT MIRASOL
Last Name:GRANZON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107-02 R JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418
Mailing Address - Country:US
Mailing Address - Phone:347-829-3890
Mailing Address - Fax:347-829-3888
Practice Address - Street 1:107-02 R JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418
Practice Address - Country:US
Practice Address - Phone:347-829-3890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-09
Last Update Date:2024-03-12
Deactivation Date:2024-01-12
Deactivation Code:
Reactivation Date:2024-03-12
Provider Licenses
StateLicense IDTaxonomies
NY050420225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist