Provider Demographics
NPI:1720494941
Name:GRANT, TELISA (APRN)
Entity Type:Individual
Prefix:
First Name:TELISA
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10257 MAGNOLIA RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-4991
Mailing Address - Country:US
Mailing Address - Phone:904-528-6357
Mailing Address - Fax:
Practice Address - Street 1:10257 MAGNOLIA RIDGE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-4991
Practice Address - Country:US
Practice Address - Phone:904-528-6357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-08
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9215166363L00000X
FLRN9215166163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty