Basic Information
| Provider Information | |||||||||
| NPI: | 1215175278 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANTHAM | ||||||||
| FirstName: | STACIE | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CFNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 587 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314248922 | ||||||||
| FaxNumber: | 7314232922 | ||||||||
| Practice Location | |||||||||
| Address1: | 587 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314248922 | ||||||||
| FaxNumber: | 7314232922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2009 | ||||||||
| LastUpdateDate: | 09/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 13513 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | APN13513 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LF0000X | APN13513 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.