Healthcare Provider Details

I. General information

NPI: 1356615447
Provider Name (Legal Business Name): ALISHA GRENADE PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2012
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21240 112TH RD
QUEENS VILLAGE NY
11429-2314
US

IV. Provider business mailing address

21240 112TH RD
QUEENS VILLAGE NY
11429-2314
US

V. Phone/Fax

Practice location:
  • Phone: 917-705-1426
  • Fax:
Mailing address:
  • Phone: 917-705-1426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF342593-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number403360
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number649732
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: