=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255207064
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARVELL GRANVILLE GRANVILLE RN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2025
-----------------------------------------------------
Last Update Date | 10/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 WHEELING ST
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80045-7211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-595-7766
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4804 GOLD LEAF CIR
-----------------------------------------------------
City | PINSON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35126-2897
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WP0809X
-----------------------------------------------------
Taxonomy Name | Adult Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | 1-189872
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------