Provider Demographics
NPI:1023857182
Name:GRANT, TANGELA RENORDA
Entity type:Individual
Prefix:
First Name:TANGELA
Middle Name:RENORDA
Last Name:GRANT
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 1:753 CREEK BOTTOM RD
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-6667
Mailing Address - Country:US
Mailing Address - Phone:678-939-4744
Mailing Address - Fax:
Practice Address - Street 1:753 CREEK BOTTOM RD
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-6667
Practice Address - Country:US
Practice Address - Phone:678-939-4744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHCP011623253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care