MEDICARE: KRYSTAL SIMONE RENE GRANT APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	11039297	FL
2	363L00000X	Nurse Practitioner	5022189	NC
3	363LF0000X	Family Nurse Practitioner	5022189	NC

General Provider Information

NPI Number	:	1992597645
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTAL SIMONE RENE GRANT APRN

Provider Business Mailing Address
First Line	:	2005 PISGAH CHURCH RD
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27455-3309
Country	:	US
Telephone Number	:	336-716-9150
Fax Number	:	336-702-9166

Provider Business Practice Location Address
First Line	:	2005 PISGAH CHURCH RD
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27455-3309
Country	:	US
Telephone Number	:	336-716-9150
Fax Number	:	336-702-9166

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2025
Last Update Date	:	03/04/2026

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