Healthcare Provider Details

I. General information

NPI: 1730634361
Provider Name (Legal Business Name): DR. NICOLE MEGAN GRANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6545 FRANCE AVE S STE 450
EDINA MN
55435-2122
US

IV. Provider business mailing address

33650 6TH AVE S STE 100
FEDERAL WAY WA
98003-6754
US

V. Phone/Fax

Practice location:
  • Phone: 952-920-8525
  • Fax:
Mailing address:
  • Phone: 937-219-5088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60663259
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11434
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: