=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013054485
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACIE GRANT N.P.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2007
-----------------------------------------------------
Last Update Date | 03/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38 HERITAGE CT
-----------------------------------------------------
City | LOCKPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14094-3616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-433-4465
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 PARKRIDGE AVE
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14215-2210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-433-4465
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number | 420749
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------