Healthcare Provider Details

I. General information

NPI: 1912652777
Provider Name (Legal Business Name): STEPHANIE ANN GRANDY MSN-ED, RN, WCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2022
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 HARDY ST
PRESQUE ISLE ME
04769-3034
US

IV. Provider business mailing address

123 HARDY ST
PRESQUE ISLE ME
04769-3034
US

V. Phone/Fax

Practice location:
  • Phone: 401-702-4298
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License NumberRN78157
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: