Healthcare Provider Details

I. General information

NPI: 1114139581
Provider Name (Legal Business Name): MARY ELIZABETH GRANT A.R.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2007
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 63RD ST S
GULFPORT FL
33707-3125
US

IV. Provider business mailing address

1120 63RD ST S
GULFPORT FL
33707-3125
US

V. Phone/Fax

Practice location:
  • Phone: 727-347-2914
  • Fax: 727-895-7225
Mailing address:
  • Phone: 727-347-2914
  • Fax: 727-895-7225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberARNP 1572502
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberARNP 1572502
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number019367
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: