Healthcare Provider Details

I. General information

NPI: 1972268092
Provider Name (Legal Business Name): TANISHA GRANT PMHNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37177 NORTH AVE
DADE CITY FL
33523
US

IV. Provider business mailing address

38345 LAKE AVE
DADE CITY FL
33525-4414
US

V. Phone/Fax

Practice location:
  • Phone: 678-973-8470
  • Fax:
Mailing address:
  • Phone: 352-467-2935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN9457208
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11041866
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: