Healthcare Provider Details

I. General information

NPI: 1437558061
Provider Name (Legal Business Name): MICAH ALEXANDER GRANT FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2014
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3549 BLUECUTT RD
COLUMBUS MS
39705-1324
US

IV. Provider business mailing address

3549 BLUECUTT RD
COLUMBUS MS
39705-1324
US

V. Phone/Fax

Practice location:
  • Phone: 662-570-4174
  • Fax: 662-570-4108
Mailing address:
  • Phone: 662-570-4174
  • Fax: 662-570-4108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberR874310
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF0115273
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: