Healthcare Provider Details

I. General information

NPI: 1114687530
Provider Name (Legal Business Name): CANDY GRISBY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2021
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 15TH PL
PLANO TX
75074-6431
US

IV. Provider business mailing address

1391 NW 136TH AVE
SUNRISE FL
33323-2800
US

V. Phone/Fax

Practice location:
  • Phone: 501-351-7469
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number841779
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: