Healthcare Provider Details

I. General information

NPI: 1265994404
Provider Name (Legal Business Name): MISS ANITA GRANTSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

738 PARKMAN DR
BEAR DE
19701-4954
US

IV. Provider business mailing address

3565 MYNDERS AVE APT 228A
MEMPHIS TN
38111-1647
US

V. Phone/Fax

Practice location:
  • Phone: 302-561-5160
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberL1-0042251
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAC004184
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberL6-0A00805
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: