Healthcare Provider Details

I. General information

NPI: 1316188311
Provider Name (Legal Business Name): LORI A GRANT DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LORI S ADDISON DPM

II. Dates (important events)

Enumeration Date: 03/20/2009
Last Update Date: 05/22/2020
Certification Date: 05/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 RODEL CV STE 2001
LAKE MARY FL
32746-5716
US

IV. Provider business mailing address

719 RODEL CV STE 2001
LAKE MARY FL
32746-5716
US

V. Phone/Fax

Practice location:
  • Phone: 407-878-4720
  • Fax: 407-878-4732
Mailing address:
  • Phone: 407-878-4720
  • Fax: 407-878-4732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO3334
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3334
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: