Healthcare Provider Details

I. General information

NPI: 1861516148
Provider Name (Legal Business Name): PENNY GRANT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3314 STEUBEN AVENUE CHILD PROTECTIVE SERVICES
BRONX NY
10467
US

IV. Provider business mailing address

86J BARRISTER DR
WHITE RIVER JUNCTION VT
05001-5500
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-5833
  • Fax:
Mailing address:
  • Phone: 802-295-1217
  • Fax: 718-515-7661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number241386
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: