Healthcare Provider Details

I. General information

NPI: 1992597645
Provider Name (Legal Business Name): KRYSTAL SIMONE RENE GRANT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2025
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 PISGAH CHURCH RD
GREENSBORO NC
27455-3309
US

IV. Provider business mailing address

2005 PISGAH CHURCH RD
GREENSBORO NC
27455-3309
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-9150
  • Fax: 336-702-9166
Mailing address:
  • Phone: 336-716-9150
  • Fax: 336-702-9166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5022189
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11039297
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5022189
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: