1730477761 NPI number — MS. KARIN E GRANN N.P.

Table of content: MS. KARIN E GRANN N.P. (NPI 1730477761)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730477761 NPI number — MS. KARIN E GRANN N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRANN
Provider First Name:
KARIN
Provider Middle Name:
E
Provider Name Prefix Text:
MS.
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730477761
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4131
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YALESVILLE
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06492-1481
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-284-1340
Provider Business Mailing Address Fax Number:
203-265-4557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 MANSFIELD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLIMANTIC
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06226-2045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-284-1340
Provider Business Practice Location Address Fax Number:
203-265-4557
Provider Enumeration Date:
07/12/2011

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: 363LA2100X , with the licence number:  4702 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163W00000X , with the licence number: 82608 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 82608 . This is a "LICENSE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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