Provider Demographics
NPI:1740845122
Name:GRANT, WANDA JEAN (REGISTERED NURSE)
Entity type:Individual
Prefix:MS
First Name:WANDA
Middle Name:JEAN
Last Name:GRANT
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43036 30TH ST W APT 131
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-4773
Mailing Address - Country:US
Mailing Address - Phone:661-481-1121
Mailing Address - Fax:
Practice Address - Street 1:117 N B ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6901
Practice Address - Country:US
Practice Address - Phone:805-681-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA348078163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health