Provider Demographics
NPI:1649814658
Name:GRANVILLE, HALLIE (ARNP)
Entity type:Individual
Prefix:
First Name:HALLIE
Middle Name:
Last Name:GRANVILLE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 W HAZEL ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-9513
Mailing Address - Country:US
Mailing Address - Phone:360-395-5550
Mailing Address - Fax:
Practice Address - Street 1:924 W HAZEL ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-9513
Practice Address - Country:US
Practice Address - Phone:360-395-5550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-01
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61012020367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife