Healthcare Provider Details

I. General information

NPI: 1215175278
Provider Name (Legal Business Name): STACIE K GRANTHAM CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2009
Last Update Date: 09/07/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

587 SKYLINE DR
JACKSON TN
38301-3938
US

IV. Provider business mailing address

587 SKYLINE DR
JACKSON TN
38301-3938
US

V. Phone/Fax

Practice location:
  • Phone: 731-424-8922
  • Fax: 731-423-2922
Mailing address:
  • Phone: 731-424-8922
  • Fax: 731-423-2922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13513
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN13513
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN13513
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: