Basic Information
| Provider Information | |||||||||
| NPI: | 1649822479 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANT | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5715 N DUXBURY PIER LN | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837145021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089211868 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2321 E GALA ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836427692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088885848 | ||||||||
| FaxNumber: | 2088880884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2019 | ||||||||
| LastUpdateDate: | 07/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 53224 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.