Healthcare Provider Details

I. General information

NPI: 1962040832
Provider Name (Legal Business Name): HALEY JAEY GRANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2019
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 MAIN ST NE
LOS LUNAS NM
87031-7409
US

IV. Provider business mailing address

957 BENJAMIN DR SE
RIO RANCHO NM
87124-1239
US

V. Phone/Fax

Practice location:
  • Phone: 505-565-0070
  • Fax:
Mailing address:
  • Phone: 580-630-9500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number55095
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: