Healthcare Provider Details

I. General information

NPI: 1982126686
Provider Name (Legal Business Name): JENNIFER MAHLBERG-GRANT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 E PLAZA DR STE 110
EAGLE ID
83616-6567
US

IV. Provider business mailing address

3325 RESEARCH WAY
CARSON CITY NV
89706-7913
US

V. Phone/Fax

Practice location:
  • Phone: 775-738-5850
  • Fax: 775-738-5856
Mailing address:
  • Phone: 775-888-6610
  • Fax: 775-888-4904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number53418
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN002287
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: