Provider Demographics
NPI:1811523186
Name:GRANT, CHARLENE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MISS
First Name:CHARLENE
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:MISS
Other - First Name:CHARLENE
Other - Middle Name:
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:61 ARLO RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-4724
Mailing Address - Country:US
Mailing Address - Phone:718-730-5224
Mailing Address - Fax:
Practice Address - Street 1:4713 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-3209
Practice Address - Country:US
Practice Address - Phone:718-284-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF345680-01363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner