Provider Demographics
NPI:1841088275
Name:SONG-GRANT, LAINEY
Entity type:Individual
Prefix:
First Name:LAINEY
Middle Name:
Last Name:SONG-GRANT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 COLUMBIA ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-2628
Mailing Address - Country:US
Mailing Address - Phone:407-416-3997
Mailing Address - Fax:
Practice Address - Street 1:6701 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2608
Practice Address - Country:US
Practice Address - Phone:832-822-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-26
Last Update Date:2025-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPENDING363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant