Provider Demographics
NPI:1013481530
Name:GRANSTAN, MAXINE M (CNA)
Entity Type:Individual
Prefix:MS
First Name:MAXINE
Middle Name:M
Last Name:GRANSTAN
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 E MAIN ST # 164
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-4655
Mailing Address - Country:US
Mailing Address - Phone:863-272-1001
Mailing Address - Fax:863-816-3128
Practice Address - Street 1:122 E MAIN ST # 164
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-4655
Practice Address - Country:US
Practice Address - Phone:863-272-1001
Practice Address - Fax:863-816-3128
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA345440376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide