Provider Demographics
NPI:1740277912
Name:GRANT, YVONNE EVADNEY (APRN)
Entity type:Individual
Prefix:
First Name:YVONNE
Middle Name:EVADNEY
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 1:722 E MEMORIAL BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-1848
Mailing Address - Country:US
Mailing Address - Phone:863-370-8847
Mailing Address - Fax:877-766-5643
Practice Address - Street 1:722 E MEMORIAL BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-1848
Practice Address - Country:US
Practice Address - Phone:863-370-8847
Practice Address - Fax:877-766-5643
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1899642363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL304139500Medicaid
FLY8755QMedicare PIN
P71243Medicare UPIN
FLY8755QMedicare Oscar/Certification