Healthcare Provider Details

I. General information

NPI: 1609221589
Provider Name (Legal Business Name): KRISTA MARIE GRANDE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 FARMINGTON AVE
FARMINGTON CT
06032-1901
US

IV. Provider business mailing address

3333 BURNET AVE ML 2015
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 860-837-7500
  • Fax:
Mailing address:
  • Phone: 513-636-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number35.142209
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number1.072626
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: