Provider Demographics
NPI:1669995437
Name:GRANT, GUILLERMO (CRNP)
Entity type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:
Last Name:GRANT
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5941 ADDISON RD
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-2166
Mailing Address - Country:US
Mailing Address - Phone:301-343-6298
Mailing Address - Fax:
Practice Address - Street 1:1220 12TH ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-3722
Practice Address - Country:US
Practice Address - Phone:202-279-1819
Practice Address - Fax:202-617-2985
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN101143363LF0000X
DCRN1011343363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily