Healthcare Provider Details

I. General information

NPI: 1811611890
Provider Name (Legal Business Name): MANDY GRAINGER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11817 CANON BLVD STE 300
NEWPORT NEWS VA
23606-4516
US

IV. Provider business mailing address

11817 CANON BLVD STE 300
NEWPORT NEWS VA
23606-4516
US

V. Phone/Fax

Practice location:
  • Phone: 757-595-8005
  • Fax: 757-595-9131
Mailing address:
  • Phone: 757-595-8005
  • Fax: 757-595-9131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number0001267550
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: