Healthcare Provider Details

I. General information

NPI: 1093256034
Provider Name (Legal Business Name): KANOSHA CREE GRADY PT, DPT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5550 WILSHIRE BLVD
LOS ANGELES CA
90036-3809
US

IV. Provider business mailing address

7129 ALTA DR
LAS VEGAS NV
89145-5207
US

V. Phone/Fax

Practice location:
  • Phone: 702-502-1018
  • Fax:
Mailing address:
  • Phone: 702-502-1018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: