Provider Demographics
NPI:1649822479
Name:GRANT, ANGELA MARIE (NP-C)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:GRANT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5715 N DUXBURY PIER LN
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83714-5021
Mailing Address - Country:US
Mailing Address - Phone:208-921-1868
Mailing Address - Fax:
Practice Address - Street 1:2321 E GALA ST STE 3
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7692
Practice Address - Country:US
Practice Address - Phone:208-888-5848
Practice Address - Fax:208-888-0884
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID53224363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily