Healthcare Provider Details

I. General information

NPI: 1710485073
Provider Name (Legal Business Name): VENETREA LAWANDA GRANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9165 OTIS AVE STE 222
INDIANAPOLIS IN
46216-2316
US

IV. Provider business mailing address

9165 OTIS AVE STE 222
INDIANAPOLIS IN
46216-2316
US

V. Phone/Fax

Practice location:
  • Phone: 317-331-7068
  • Fax: 317-723-3772
Mailing address:
  • Phone: 317-331-7068
  • Fax: 317-723-3772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number170140631
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number170140631
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: