Provider Demographics
NPI:1669611463
Name:GRANTHAM, KIMBERLY LEACH (CRNA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LEACH
Last Name:GRANTHAM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1171 PELICAN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-8539
Mailing Address - Country:US
Mailing Address - Phone:318-780-0716
Mailing Address - Fax:
Practice Address - Street 1:1171 PELICAN CREEK DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-8539
Practice Address - Country:US
Practice Address - Phone:318-780-0716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-18
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN097823-AP05716367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered