Provider Demographics
NPI:1649883133
Name:GRANGE, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GRANGE
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 1:2414 ACADIANA LN
Mailing Address - Street 2:
Mailing Address - City:SEABROOK
Mailing Address - State:TX
Mailing Address - Zip Code:77586-8309
Mailing Address - Country:US
Mailing Address - Phone:180-147-3396
Mailing Address - Fax:801-797-1220
Practice Address - Street 1:581 W 1600 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-2571
Practice Address - Country:US
Practice Address - Phone:180-147-3396
Practice Address - Fax:801-797-1220
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker