1225142722 NPI number — SANDRA LYNN GRANT N.P.

Table of content: SANDRA LYNN GRANT N.P. (NPI 1225142722)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225142722 NPI number — SANDRA LYNN GRANT N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANT
Provider First Name:
SANDRA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRANT
Provider Other First Name:
SANDRA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
N.P.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1225142722
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12002 TRAFALGAR AVE
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79424-7668
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-744-7764
Provider Business Mailing Address Fax Number:
806-744-7761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12002 TRAFALGAR AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79424-7668
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-744-7764
Provider Business Practice Location Address Fax Number:
806-744-7761
Provider Enumeration Date:
08/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  616710 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: AP112706 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8N7015 . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 164669701 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 144428100 . This is a "FIRST CARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: AP112706 . This is a "APRN LICENSE NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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