Healthcare Provider Details

I. General information

NPI: 1619755816
Provider Name (Legal Business Name): GRANT THOMAS APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 N DONNELLY ST STE 109
MOUNT DORA FL
32757-6969
US

IV. Provider business mailing address

PO BOX 237224
COCOA FL
32923-7224
US

V. Phone/Fax

Practice location:
  • Phone: 321-222-7842
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11027438
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: