Healthcare Provider Details

I. General information

NPI: 1164938080
Provider Name (Legal Business Name): MS. TANYA RENEE GRANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3536 SWEETWATER SPRINGS BLVD #D17
SPRING VALLEY CA
91977
US

IV. Provider business mailing address

3536 SWEETWATER SPRINGS BLVD #D17
SPRING VALLEY CA
91977
US

V. Phone/Fax

Practice location:
  • Phone: 619-370-5429
  • Fax:
Mailing address:
  • Phone: 619-370-5429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN228680
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberVN228680
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: