Healthcare Provider Details

I. General information

NPI: 1144002395
Provider Name (Legal Business Name): JUSTINA GRANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2023
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 GROVE RD STE M123
PITTSBURGH PA
15236-5602
US

IV. Provider business mailing address

2383 WILLIAM PENN AVE
JOHNSTOWN PA
15909-1258
US

V. Phone/Fax

Practice location:
  • Phone: 412-677-9100
  • Fax:
Mailing address:
  • Phone: 814-771-6918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP028457
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: