Provider Demographics
NPI:1982646485
Name:GRANGE, LINETTE I (DO)
Entity Type:Individual
Prefix:
First Name:LINETTE
Middle Name:I
Last Name:GRANGE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 NEW VISION DR BLDG B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1703
Mailing Address - Country:US
Mailing Address - Phone:260-266-6013
Mailing Address - Fax:
Practice Address - Street 1:1025 MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-1425
Practice Address - Country:US
Practice Address - Phone:260-563-7421
Practice Address - Fax:260-569-2284
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003654207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201007920Medicaid
INP01123184OtherRR MEDICARE
IN090540012Medicare PIN
IN201007920Medicaid