Basic Information
| Provider Information | |||||||||
| NPI: | 1700874815 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRANDAL | ||||||||
| FirstName: | MERCY | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 S PINE ISLAND RD | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333243920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052458050 | ||||||||
| FaxNumber: | 3052458059 | ||||||||
| Practice Location | |||||||||
| Address1: | 3084 NE 41ST TER | ||||||||
| Address2: | |||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330306619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052458050 | ||||||||
| FaxNumber: | 3052458059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 10/04/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | ARNP 9184215 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 307126000 | 05 | FL | MEDICAID |