Healthcare Provider Details

I. General information

NPI: 1487594214
Provider Name (Legal Business Name): CAROLYN ELIZABETH GRANT AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 W HARRISON ST STE 970
CHICAGO IL
60607-3106
US

IV. Provider business mailing address

333 S DESPLAINES ST APT 605
CHICAGO IL
60661-5508
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-4120
  • Fax:
Mailing address:
  • Phone: 248-227-8451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number209035091
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: