Healthcare Provider Details

I. General information

NPI: 1659633840
Provider Name (Legal Business Name): REBECCA GRANDY APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 06/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4720 DOLLARWAY RD
PINE BLUFF AR
71602-4126
US

IV. Provider business mailing address

8324 WHITEVILLE RD
PINE BLUFF AR
71603-9313
US

V. Phone/Fax

Practice location:
  • Phone: 870-536-3279
  • Fax: 870-536-3283
Mailing address:
  • Phone: 870-879-1924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA03707
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: