=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114071404
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JANE M GRANT NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 07/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 N MAIN ST STE 200
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23434-4564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-934-1003
-----------------------------------------------------
Fax | 757-934-1660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 N MAIN ST STE 200
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23434-4564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-934-1003
-----------------------------------------------------
Fax | 757-934-1660
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 0024084723
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------