Basic Information
| Provider Information | |||||||||
| NPI: | 1841862729 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRANGER | ||||||||
| FirstName: | KAMARIO | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1008 AZALEA DR | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393672499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015092584 | ||||||||
| FaxNumber: | 6015092585 | ||||||||
| Practice Location | |||||||||
| Address1: | 1008 AZALEA DR | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393672499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015092584 | ||||||||
| FaxNumber: | 6015092585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2021 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 220985 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 904632 | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.