Provider Demographics
NPI:1982126686
Name:MAHLBERG-GRANT, JENNIFER (APRN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MAHLBERG-GRANT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3325 RESEARCH WAY
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89706-7913
Mailing Address - Country:US
Mailing Address - Phone:775-888-6610
Mailing Address - Fax:775-888-4904
Practice Address - Street 1:951 E PLAZA DR
Practice Address - Street 2:STE 110
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6567
Practice Address - Country:US
Practice Address - Phone:775-738-5850
Practice Address - Fax:775-738-5856
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID53418363LW0102X
NVAPRN002287363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVAPRN002287OtherAPRN LICENSE