1548358203 NPI number — MRS. ROBERTA ANN GRANT FNP C

Table of content: MRS. ROBERTA ANN GRANT FNP C (NPI 1548358203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548358203 NPI number — MRS. ROBERTA ANN GRANT FNP C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANT
Provider First Name:
ROBERTA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DONALD
Provider Other First Name:
ROBERTA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1548358203
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
571 SAINT JOSEPHS BLVD FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELMIRA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14901-3230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-271-2050
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 JOHN ROEMMELT DR STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HORSEHEADS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14845-8304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-795-2828
Provider Business Practice Location Address Fax Number:
607-795-2829
Provider Enumeration Date:
10/10/2006

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: 363L00000X , with the licence number:  F3347761 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02850613 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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