Healthcare Provider Details

I. General information

NPI: 1679850168
Provider Name (Legal Business Name): LASHONDA GRANT C.N.A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2011
Last Update Date: 11/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2134 BO PEEP DR W
JACKSONVILLE FL
32210-2918
US

IV. Provider business mailing address

2134 BO PEEP DR W
JACKSONVILLE FL
32210-2918
US

V. Phone/Fax

Practice location:
  • Phone: 904-476-9743
  • Fax: 904-786-9759
Mailing address:
  • Phone: 904-476-9743
  • Fax: 904-786-9759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number123348
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: