Healthcare Provider Details

I. General information

NPI: 1700219789
Provider Name (Legal Business Name): LADALE L GRANT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3011 N MICHIGAN ST
PITTSBURG KS
66762-2546
US

IV. Provider business mailing address

3011 N MICHIGAN ST STE B
PITTSBURG KS
66762-2546
US

V. Phone/Fax

Practice location:
  • Phone: 620-231-9873
  • Fax: 620-231-5062
Mailing address:
  • Phone: 620-231-9873
  • Fax: 620-231-5062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2013029344
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number76396
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: