Healthcare Provider Details

I. General information

NPI: 1003016700
Provider Name (Legal Business Name): ALISSA MICHELLE GRANT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 HIGHWAY 71 N
MENA AR
71953-4304
US

IV. Provider business mailing address

900 HIGHWAY 71 N
MENA AR
71953-4304
US

V. Phone/Fax

Practice location:
  • Phone: 479-394-5439
  • Fax: 479-394-4357
Mailing address:
  • Phone: 479-394-5439
  • Fax: 479-394-4357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-7744
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: