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General NPI Number Information
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NPI Number | 1215163175
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Entity Type | Individual
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Provider Name | DENISE RICKETTS GRANT M.D.
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Gender | Female
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Dates
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Enumeration Date | 06/05/2009
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Last Update Date | 09/02/2025
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Provider Practice Location Address
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Address Line | 1400 SE GOLDTREE DR STE 207
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City | PORT ST LUCIE
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State | FL
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Zip | 34952-7583
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Country | US
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Telephone | 772-249-2494
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Fax |
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Provider Business Mailing Address
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Address Line | 1713 HWY 441 NORTH STE C
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City | OKEECHOBEE
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State | FL
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Zip | 34972
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Country | US
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Telephone | 863-467-2159
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Fax | 863-763-0681
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME 114478
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License Number State | FL
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