Healthcare Provider Details

I. General information

NPI: 1508405044
Provider Name (Legal Business Name): MRS. ABIOLA J GRANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2020
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1952 WHITNEY AVE
HAMDEN CT
06517-1209
US

IV. Provider business mailing address

6 WOOD CREEK DR
MONROE CT
06468-2273
US

V. Phone/Fax

Practice location:
  • Phone: 203-848-1803
  • Fax:
Mailing address:
  • Phone: 203-395-5092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8498
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: