Healthcare Provider Details

I. General information

NPI: 1124269998
Provider Name (Legal Business Name): CARON C GRANT-ELLIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2009
Last Update Date: 03/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 S BELLVIEW
MESA AZ
85204-2504
US

IV. Provider business mailing address

3691 W YELLOW PEAK DR
QUEEN CREEK AZ
85242-3076
US

V. Phone/Fax

Practice location:
  • Phone: 480-649-1141
  • Fax:
Mailing address:
  • Phone: 480-677-4160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberRN133597
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: