Provider Demographics
NPI:1932132917
Name:LOFTON, GRANT KEITH (CFNP)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:KEITH
Last Name:LOFTON
Suffix:
Gender:M
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 CHARLIE DIXON RD
Mailing Address - Street 2:
Mailing Address - City:BRAXTON
Mailing Address - State:MS
Mailing Address - Zip Code:39044-9315
Mailing Address - Country:US
Mailing Address - Phone:601-362-4471
Mailing Address - Fax:601-364-1425
Practice Address - Street 1:1500 E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:601-364-1425
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR587052363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care