Provider Demographics
NPI:1811323934
Name:GRANBERRY, DOROTHY RUTH
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:RUTH
Last Name:GRANBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14602 N 19TH AVE
Mailing Address - Street 2:148
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-7102
Mailing Address - Country:US
Mailing Address - Phone:480-347-5702
Mailing Address - Fax:602-252-0830
Practice Address - Street 1:4220 N 20TH AVE
Practice Address - Street 2:100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-5101
Practice Address - Country:US
Practice Address - Phone:602-254-9701
Practice Address - Fax:602-252-0830
Is Sole Proprietor?:No
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other