MEDICARE: MRS. CANDY GRISBY RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC0400X	Case Management Registered Nurse	841779	TX

General Provider Information

NPI Number	:	1114687530
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CANDY GRISBY RN

Provider Business Mailing Address
First Line	:	1391 NW 136TH AVE
Second Line	:
City	:	SUNRISE
State	:	FL
Zip	:	33323-2800
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1717 15TH PL
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75074-6431
Country	:	US
Telephone Number	:	501-351-7469
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2021
Last Update Date	:	12/27/2021

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