Provider Demographics
NPI:1336548056
Name:GRANT, LISA (OMD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7381 PRAIRIE FALCON RD STE 140
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0812
Mailing Address - Country:US
Mailing Address - Phone:702-539-9185
Mailing Address - Fax:
Practice Address - Street 1:7381 PRAIRIE FALCON RD STE 140
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0812
Practice Address - Country:US
Practice Address - Phone:702-539-9185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-19
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1032171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
20-8269015OtherEIN