Provider Demographics
NPI:1811251234
Name:GRANT, DAVID EDWARD (MSN, APRN, NP-C)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:EDWARD
Last Name:GRANT
Suffix:
Gender:M
Credentials:MSN, APRN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12470 TELECOM DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0904
Mailing Address - Country:US
Mailing Address - Phone:813-871-8079
Mailing Address - Fax:
Practice Address - Street 1:12470 TELECOM DR
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0904
Practice Address - Country:US
Practice Address - Phone:813-871-8079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9469490363LA2200X
KY3007436363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1811251234Medicaid