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General NPI Number Information
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NPI Number | 1982126686
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Entity Type | Individual
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Provider Name | JENNIFER MAHLBERG-GRANT APRN
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Gender | Female
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Dates
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Enumeration Date | 07/13/2017
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Last Update Date | 01/12/2021
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Provider Practice Location Address
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Address Line | 951 E PLAZA DR STE 110
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City | EAGLE
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State | ID
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Zip | 83616-6567
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Country | US
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Telephone | 775-738-5850
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Fax | 775-738-5856
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Provider Business Mailing Address
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Address Line | 3325 RESEARCH WAY
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City | CARSON CITY
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State | NV
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Zip | 89706-7913
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Country | US
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Telephone | 775-888-6610
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Fax | 775-888-4904
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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 | 363LW0102X
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Taxonomy Name | Women's Health Nurse Practitioner
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License Number | 53418
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | APRN002287
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License Number State | NV
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