Healthcare Provider Details

I. General information

NPI: 1962629428
Provider Name (Legal Business Name): MARILOU GRANT CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 OAK ST
OLD FORGE PA
18518-1619
US

IV. Provider business mailing address

518 HILL ST
DURYEA PA
18642-1619
US

V. Phone/Fax

Practice location:
  • Phone: 570-457-7150
  • Fax: 570-457-8611
Mailing address:
  • Phone: 570-457-0218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberUP004462B
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: