Healthcare Provider Details

I. General information

NPI: 1164929212
Provider Name (Legal Business Name): CHERYL ANN GRANT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 FOURTH STREET
MALONE NY
12953
US

IV. Provider business mailing address

15 FOURTH STREET
MALONE NY
12953
US

V. Phone/Fax

Practice location:
  • Phone: 518-481-8160
  • Fax: 518-481-8161
Mailing address:
  • Phone: 518-481-8160
  • Fax: 518-481-8161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number444808-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: