Healthcare Provider Details

I. General information

NPI: 1104814516
Provider Name (Legal Business Name): LANCE A GRIZZARD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 01/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8260 ATLEE RD
MECHANICSVILLE VA
23116-1844
US

IV. Provider business mailing address

3100 SPRING FOREST RD STE 130
RALEIGH NC
27616-2880
US

V. Phone/Fax

Practice location:
  • Phone: 804-288-6258
  • Fax: 804-282-9921
Mailing address:
  • Phone: 888-280-9533
  • Fax: 919-873-9821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001154508
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024166429
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: